Provider Demographics
NPI:1649261231
Name:SOUFERIAN, ROBERT BABAK (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BABAK
Last Name:SOUFERIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BABAK
Other - Middle Name:
Other - Last Name:SOUFERIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8301 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4402
Mailing Address - Country:US
Mailing Address - Phone:646-279-1346
Mailing Address - Fax:
Practice Address - Street 1:8301 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-4402
Practice Address - Country:US
Practice Address - Phone:646-279-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0500401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02289476Medicaid