Provider Demographics
NPI:1619389301
Name:FATTAHI, PEYMAN (DDS)
Entity Type:Individual
Prefix:
First Name:PEYMAN
Middle Name:
Last Name:FATTAHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 PENTAGON PARK BLVD.
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431
Mailing Address - Country:US
Mailing Address - Phone:937-705-0257
Mailing Address - Fax:
Practice Address - Street 1:3286 PENTAGON PARK BLVD.
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-705-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-024177122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist