Provider Demographics
NPI:1972286177
Name:MAGHSOUDLOO, SEPEHR (DMD)
Entity Type:Individual
Prefix:
First Name:SEPEHR
Middle Name:
Last Name:MAGHSOUDLOO
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 1:3920 MYSTIC VALLEY PKWY APT 1002
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6910
Mailing Address - Country:US
Mailing Address - Phone:781-475-4821
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:617-358-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1860011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist