Provider Demographics
NPI:1881744563
Name:AZIZI, KHOSROW BENJAMIN (DMD)
Entity type:Individual
Prefix:DR
First Name:KHOSROW
Middle Name:BENJAMIN
Last Name:AZIZI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BENJAMIN
Other - Middle Name:K
Other - Last Name:AZIZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:242 N KESWICK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-4804
Mailing Address - Country:US
Mailing Address - Phone:215-576-6414
Mailing Address - Fax:215-576-8497
Practice Address - Street 1:242 N KESWICK AVE
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-4804
Practice Address - Country:US
Practice Address - Phone:215-576-6414
Practice Address - Fax:215-576-8497
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025908L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA505604OtherUNITED CONCORDIA ID NUMBE
PA232825711OtherTAX ID NUMBER