Provider Demographics
NPI:1457883019
Name:MOSTATABZADEH, AMIR
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:MOSTATABZADEH
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 1:2119 W BRANDON BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4731
Mailing Address - Country:US
Mailing Address - Phone:239-405-5592
Mailing Address - Fax:
Practice Address - Street 1:2119 W BRANDON BLVD STE F
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4731
Practice Address - Country:US
Practice Address - Phone:239-405-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL228891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program