Provider Demographics
NPI:1821878786
Name:AGHELI, NASTARAN (DDS,MS)
Entity Type:Individual
Prefix:
First Name:NASTARAN
Middle Name:
Last Name:AGHELI
Suffix:
Gender:F
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22120 BROCKSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4788
Mailing Address - Country:US
Mailing Address - Phone:240-780-6064
Mailing Address - Fax:
Practice Address - Street 1:2034 N STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4410
Practice Address - Country:US
Practice Address - Phone:815-929-0222
Practice Address - Fax:815-929-0333
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2952000831122300000X
IL0190346411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist