Provider Demographics
NPI:1922434828
Name:DEHGHANI, SIAVASH (DMD)
Entity Type:Individual
Prefix:
First Name:SIAVASH
Middle Name:
Last Name:DEHGHANI
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 1:254 GREYLOCK PKWY APT 2
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-2723
Mailing Address - Country:US
Mailing Address - Phone:617-462-5483
Mailing Address - Fax:
Practice Address - Street 1:254 GREYLOCK PKWY APT 2
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-2723
Practice Address - Country:US
Practice Address - Phone:617-462-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DR02643122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist