Provider Demographics
NPI:1659303329
Name:MIR MADJLESSI, NIMA (DDS,MSD,PA)
Entity Type:Individual
Prefix:DR
First Name:NIMA
Middle Name:
Last Name:MIR MADJLESSI
Suffix:
Gender:M
Credentials:DDS,MSD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E7 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3336
Mailing Address - Country:US
Mailing Address - Phone:732-651-8470
Mailing Address - Fax:732-651-8033
Practice Address - Street 1:E7 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3336
Practice Address - Country:US
Practice Address - Phone:732-651-8470
Practice Address - Fax:732-651-8033
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ205081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1710151089Medicaid