Provider Demographics
NPI:1851765069
Name:MINOOFAR, MAZIAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAZIAR
Middle Name:
Last Name:MINOOFAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 290
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6402
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:
Practice Address - Street 1:1816 N ZARAGOZA RD
Practice Address - Street 2:STE 103
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8019
Practice Address - Country:US
Practice Address - Phone:323-205-6294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31549122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist