Provider Demographics
NPI:1912065632
Name:HEDAYATI, MASHID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MASHID
Middle Name:
Last Name:HEDAYATI
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 1:1315 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1948
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:860-423-4629
Practice Address - Street 1:1315 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1948
Practice Address - Country:US
Practice Address - Phone:860-450-7471
Practice Address - Fax:860-423-4629
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0080731223G0001X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice