Provider Demographics
NPI:1629273776
Name:DASTJERDI, DIBA (DMD)
Entity Type:Individual
Prefix:
First Name:DIBA
Middle Name:
Last Name:DASTJERDI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 NEW EDGERLY ROAD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-262-5880
Mailing Address - Fax:617-859-8804
Practice Address - Street 1:68 NEW EDGERLY ROAD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-262-5880
Practice Address - Fax:617-859-8804
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice