Provider Demographics
NPI:1659524692
Name:EFTEKHARI, MASSOUD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MASSOUD
Middle Name:
Last Name:EFTEKHARI
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 1:14524 N 106TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-8595
Mailing Address - Country:US
Mailing Address - Phone:602-430-8462
Mailing Address - Fax:928-634-1363
Practice Address - Street 1:830 S MAIN ST STE 1D
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4621
Practice Address - Country:US
Practice Address - Phone:602-430-8462
Practice Address - Fax:928-634-1363
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4954122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4954OtherDENTIST LICENSE
AZ496932Medicaid