Provider Demographics
NPI:1750567046
Name:KOHANZADEH, JACK (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KOHANZADEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JACQUE
Other - Middle Name:
Other - Last Name:KOHANZADEH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:233 E SHORE RD
Mailing Address - Street 2:SUITE # 107
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2433
Mailing Address - Country:US
Mailing Address - Phone:516-482-7557
Mailing Address - Fax:
Practice Address - Street 1:233 E SHORE RD
Practice Address - Street 2:SUITE # 107
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2433
Practice Address - Country:US
Practice Address - Phone:516-482-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY0340441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice