Provider Demographics
NPI:1659459501
Name:GOODARZI, MOHAMMAD (DMD)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:GOODARZI
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 1:627 W LUMSDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-661-8360
Mailing Address - Fax:813-657-7180
Practice Address - Street 1:627 W LUMSDEN ROAD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-661-8360
Practice Address - Fax:813-657-7180
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL138571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice