Provider Demographics
NPI:1841078193
Name:KASHANIMOGHADDAM, ROHAM
Entity type:Individual
Prefix:
First Name:ROHAM
Middle Name:
Last Name:KASHANIMOGHADDAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N MCCLURG CT APT 3011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4120
Mailing Address - Country:US
Mailing Address - Phone:773-603-6232
Mailing Address - Fax:
Practice Address - Street 1:6258 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4610
Practice Address - Country:US
Practice Address - Phone:773-777-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist