Provider Demographics
NPI:1922671023
Name:HEDAYAT, MOSTAFA
Entity Type:Individual
Prefix:DR
First Name:MOSTAFA
Middle Name:
Last Name:HEDAYAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 W BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7392
Mailing Address - Country:US
Mailing Address - Phone:602-237-0613
Mailing Address - Fax:
Practice Address - Street 1:5045 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-7392
Practice Address - Country:US
Practice Address - Phone:602-237-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0111201223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty