Provider Demographics
NPI:1023480860
Name:KHANBABAPOUR, MEHRAN
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:KHANBABAPOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6975 E PRINCESS DR APT 3120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4234
Mailing Address - Country:US
Mailing Address - Phone:310-991-5234
Mailing Address - Fax:
Practice Address - Street 1:2755 S 99TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-1404
Practice Address - Country:US
Practice Address - Phone:623-478-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0103511223G0001X
MO2015021512122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty