Provider Demographics
NPI:1700936432
Name:MASHAYEKHI, ALI (DMD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MASHAYEKHI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 MAGOUN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4854
Mailing Address - Country:US
Mailing Address - Phone:781-391-4352
Mailing Address - Fax:
Practice Address - Street 1:0 GOVERNORS AVE
Practice Address - Street 2:SUITE #23
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3025
Practice Address - Country:US
Practice Address - Phone:781-350-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0219461Medicaid