Provider Demographics
NPI:1710360797
Name:ATASHZAREH, MOHAMMEDREZA
Entity Type:Individual
Prefix:
First Name:MOHAMMEDREZA
Middle Name:
Last Name:ATASHZAREH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 HUDSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3727
Mailing Address - Country:US
Mailing Address - Phone:503-484-6060
Mailing Address - Fax:
Practice Address - Street 1:7030 35TH AVE NE STE B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-5917
Practice Address - Country:US
Practice Address - Phone:205-526-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60579051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist