Provider Demographics
NPI:1710112800
Name:SADRI, HOMAYOUN (DDS)
Entity Type:Individual
Prefix:
First Name:HOMAYOUN
Middle Name:
Last Name:SADRI
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 1:1914 MCKINNEY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2954
Mailing Address - Country:US
Mailing Address - Phone:336-570-6415
Mailing Address - Fax:336-221-1264
Practice Address - Street 1:1914 MCKINNEY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2954
Practice Address - Country:US
Practice Address - Phone:336-570-6415
Practice Address - Fax:336-221-1264
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87541223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913811Medicaid