Provider Demographics
NPI:1184283111
Name:MAHDAVI, BROOKE (DMD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CHESTER AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1201
Mailing Address - Country:US
Mailing Address - Phone:239-940-0867
Mailing Address - Fax:
Practice Address - Street 1:955 MEMORIAL DR SE STE 530
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1566
Practice Address - Country:US
Practice Address - Phone:770-800-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0153461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics