Provider Demographics
NPI:1740635002
Name:GOLSHIRI, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GOLSHIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BIDDLE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 BIDDLE AVE STE 204
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3972
Practice Address - Country:US
Practice Address - Phone:302-428-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-24
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00014001223G0001X
DEG0001400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice