Provider Demographics
NPI:1912584764
Name:MIRFENDERESKI, PAYAM
Entity Type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:MIRFENDERESKI
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 1:345 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4020
Mailing Address - Country:US
Mailing Address - Phone:212-998-9743
Mailing Address - Fax:212-995-4767
Practice Address - Street 1:345 E 24TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4020
Practice Address - Country:US
Practice Address - Phone:212-998-9743
Practice Address - Fax:212-995-4767
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063834125Q00000X, 122300000X
CA106713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No125Q00000XDental ProvidersOral Medicinist