Provider Demographics
NPI:1649818048
Name:TAHMASEBI, SAFA
Entity type:Individual
Prefix:
First Name:SAFA
Middle Name:
Last Name:TAHMASEBI
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 1:355 W MARTIN LUTHER KING BLVD APT 2109
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3081
Mailing Address - Country:US
Mailing Address - Phone:980-339-6333
Mailing Address - Fax:
Practice Address - Street 1:481 MUNN RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-0014
Practice Address - Country:US
Practice Address - Phone:704-323-5390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94011223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics