Provider Demographics
NPI:1699840371
Name:MOIN, KAMBIZ (DMD, MPH)
Entity Type:Individual
Prefix:
First Name:KAMBIZ
Middle Name:
Last Name:MOIN
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 S MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-5141
Mailing Address - Country:US
Mailing Address - Phone:603-669-4503
Mailing Address - Fax:603-669-9160
Practice Address - Street 1:765 S MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-5141
Practice Address - Country:US
Practice Address - Phone:603-669-4503
Practice Address - Fax:603-669-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH23981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics