Provider Demographics
NPI:1992377832
Name:FARAHMANDNIA, FARZIN (DDS)
Entity Type:Individual
Prefix:
First Name:FARZIN
Middle Name:
Last Name:FARAHMANDNIA
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 1:2840 HOWE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4525
Mailing Address - Country:US
Mailing Address - Phone:916-308-2989
Mailing Address - Fax:
Practice Address - Street 1:430 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5115
Practice Address - Country:US
Practice Address - Phone:920-431-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10026771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice