Provider Demographics
NPI:1922677962
Name:SHOKOUFI MOGHIMAN, KAVEH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAVEH
Middle Name:
Last Name:SHOKOUFI MOGHIMAN
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 1:10900 MEDLOCK BRIDGE RD STE 303
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1505
Mailing Address - Country:US
Mailing Address - Phone:404-790-2331
Mailing Address - Fax:
Practice Address - Street 1:10900 MEDLOCK BRIDGE RD STE 303
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1505
Practice Address - Country:US
Practice Address - Phone:470-545-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1223511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice