Provider Demographics
NPI:1821524398
Name:KHOSHNEVISZADEH, ARASH (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:ARASH
Middle Name:
Last Name:KHOSHNEVISZADEH
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVERFRONT DR APT 1203
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4538
Mailing Address - Country:US
Mailing Address - Phone:630-946-4651
Mailing Address - Fax:
Practice Address - Street 1:32316 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-6109
Practice Address - Country:US
Practice Address - Phone:734-523-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI29016005941223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program