Provider Demographics
NPI:1629817358
Name:VAHDATIAN, MAHSA (DMD)
Entity type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:VAHDATIAN
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 1:3756 S PARNELL AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1971
Mailing Address - Country:US
Mailing Address - Phone:312-834-5480
Mailing Address - Fax:
Practice Address - Street 1:3756 S PARNELL AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1971
Practice Address - Country:US
Practice Address - Phone:312-834-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0350881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice