Provider Demographics
NPI:1700970365
Name:MAHMOODI, ELHAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELHAM
Middle Name:
Last Name:MAHMOODI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 BIELENBERG DR
Mailing Address - Street 2:STE 210
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1415
Mailing Address - Country:US
Mailing Address - Phone:651-414-0208
Mailing Address - Fax:651-414-0390
Practice Address - Street 1:563 BIELENBERG DR
Practice Address - Street 2:210
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1415
Practice Address - Country:US
Practice Address - Phone:651-414-0208
Practice Address - Fax:651-414-0390
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist