Provider Demographics
NPI:1942514567
Name:SEDAGHAT-DARVISH, TALIA TANNAZ (DMD)
Entity Type:Individual
Prefix:DR
First Name:TALIA
Middle Name:TANNAZ
Last Name:SEDAGHAT-DARVISH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1016
Mailing Address - Country:US
Mailing Address - Phone:917-952-4595
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1016
Practice Address - Country:US
Practice Address - Phone:917-952-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0550961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice