Provider Demographics
NPI:1982676508
Name:EGHTEDARI, MASOUD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:
Last Name:EGHTEDARI
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:PSC 819 BOX18-328
Mailing Address - Street 2:
Mailing Address - City:FPO AE
Mailing Address - State:SPAIN
Mailing Address - Zip Code:09645
Mailing Address - Country:ES
Mailing Address - Phone:0113495-682-3768
Mailing Address - Fax:
Practice Address - Street 1:BLDG H 2005 KNIGHT LANE
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:858-577-4725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47771223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics