Provider Demographics
NPI:1831291301
Name:ELAHI, SORAYA (DMD, MSCD)
Entity Type:Individual
Prefix:
First Name:SORAYA
Middle Name:
Last Name:ELAHI
Suffix:
Gender:F
Credentials:DMD, MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOLDMAN CIR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1371
Mailing Address - Country:US
Mailing Address - Phone:617-686-0204
Mailing Address - Fax:
Practice Address - Street 1:563 BROADWAY STE 23
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3749
Practice Address - Country:US
Practice Address - Phone:617-389-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0272892Medicare ID - Type UnspecifiedMASSHEALTH