Provider Demographics
NPI:1003218009
Name:KESHMIRI, REZA (DDS)
Entity type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:KESHMIRI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MOHAMMADREZA
Other - Middle Name:
Other - Last Name:KESHMIRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:9 BRONCO CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6124
Mailing Address - Country:US
Mailing Address - Phone:510-206-4854
Mailing Address - Fax:
Practice Address - Street 1:9 BRONCO CT
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-6124
Practice Address - Country:US
Practice Address - Phone:510-206-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD156961223G0001X, 122300000X
DCDEN1001440122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist