Provider Demographics
NPI:1245476423
Name:MOTLAGH, SHOKOFEH (DMD)
Entity type:Individual
Prefix:DR
First Name:SHOKOFEH
Middle Name:
Last Name:MOTLAGH
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 1:2200 E CEDAR AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1958
Mailing Address - Country:US
Mailing Address - Phone:928-637-6673
Mailing Address - Fax:928-637-6665
Practice Address - Street 1:2200 E CEDAR AVE STE 5
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1958
Practice Address - Country:US
Practice Address - Phone:928-637-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5711122300000X
AZ88321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentistGroup - Single Specialty