Provider Demographics
NPI:1952321259
Name:MAZHARI, REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:MAZHARI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 COUNTY ROAD B W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4527
Mailing Address - Country:US
Mailing Address - Phone:651-489-0161
Mailing Address - Fax:651-489-9938
Practice Address - Street 1:708 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4527
Practice Address - Country:US
Practice Address - Phone:651-489-0161
Practice Address - Fax:651-489-9938
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND112251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice