Provider Demographics
NPI:1598989741
Name:HAIDARI, MEHRON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEHRON
Middle Name:
Last Name:HAIDARI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2120
Mailing Address - Country:US
Mailing Address - Phone:770-451-0451
Mailing Address - Fax:770-936-9774
Practice Address - Street 1:3652 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2120
Practice Address - Country:US
Practice Address - Phone:770-451-0451
Practice Address - Fax:770-936-9774
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA594319427AMedicaid
GA594319427AMedicaid