Provider Demographics
NPI:1891920443
Name:DELAVARI, NEDA ENSIEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:NEDA
Middle Name:ENSIEH
Last Name:DELAVARI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ENSIEH
Other - Middle Name:
Other - Last Name:DELAVARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:6666 W PEORIA AVE ST#117
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302
Mailing Address - Country:US
Mailing Address - Phone:623-878-6000
Mailing Address - Fax:623-773-2230
Practice Address - Street 1:6666 W PEORIA AVE STE 117
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-7016
Practice Address - Country:US
Practice Address - Phone:623-878-6000
Practice Address - Fax:623-773-2230
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS60642OtherLICENSE NO