Provider Demographics
NPI:1669544540
Name:FARZANEH, MASOUD K (DDS)
Entity type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:K
Last Name:FARZANEH
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 1:105 N CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-2413
Mailing Address - Country:US
Mailing Address - Phone:863-869-8888
Mailing Address - Fax:863-869-8880
Practice Address - Street 1:105 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-2413
Practice Address - Country:US
Practice Address - Phone:863-869-8888
Practice Address - Fax:863-869-8880
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 138171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071188800Medicaid
FLDN 13817OtherLICENSE #
FLDN 13817OtherLICENSE #