Provider Demographics
NPI:1851974570
Name:BAKHTIARI, PERSIAH
Entity Type:Individual
Prefix:
First Name:PERSIAH
Middle Name:
Last Name:BAKHTIARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 HARRISON AVE APT 507
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3478
Mailing Address - Country:US
Mailing Address - Phone:650-305-0364
Mailing Address - Fax:
Practice Address - Street 1:135 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3603
Practice Address - Country:US
Practice Address - Phone:508-425-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18598391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry