Provider Demographics
NPI:1396800702
Name:RADMAND, REZA (DMD)
Entity type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:RADMAND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5966
Mailing Address - Country:US
Mailing Address - Phone:203-375-1649
Mailing Address - Fax:203-377-5251
Practice Address - Street 1:2318 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5966
Practice Address - Country:US
Practice Address - Phone:203-375-1649
Practice Address - Fax:203-377-5251
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38118122300000X
CT102641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91540Medicaid