Provider Demographics
NPI:1841402500
Name:FEREIDOUNI, AMIR (DMD, CAGS)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:FEREIDOUNI
Suffix:
Gender:M
Credentials:DMD, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 MYSTIC VALLEY PKWY APT 919
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3985 MYSTIC VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-0000
Practice Address - Country:US
Practice Address - Phone:781-396-6613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20309122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist