Provider Demographics
NPI:1649041641
Name:MOTAMEDI, AMIRSABA (DDS)
Entity type:Individual
Prefix:
First Name:AMIRSABA
Middle Name:
Last Name:MOTAMEDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-5504
Mailing Address - Country:US
Mailing Address - Phone:856-495-5066
Mailing Address - Fax:
Practice Address - Street 1:1954 FRUITVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-3916
Practice Address - Country:US
Practice Address - Phone:717-610-5934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02986900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist