Provider Demographics
NPI:1649256173
Name:BAGHAEI-RAD, MOHAMMAD
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:BAGHAEI-RAD
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 1:5010 STATE HWY 30
Mailing Address - Street 2:STE 203
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-842-9850
Mailing Address - Fax:518-842-3854
Practice Address - Street 1:5010 STATE HWY 30
Practice Address - Street 2:STE 203
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-842-9850
Practice Address - Fax:518-842-3854
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0363281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00756565Medicaid
32685OtherMVP
0004240OtherDORAL
NY00756565Medicaid
0004240OtherDORAL