Provider Demographics
NPI:1912989963
Name:ASHTIANI, MEHRDAD HAZRATI (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEHRDAD
Middle Name:HAZRATI
Last Name:ASHTIANI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 E GREENWAY RD
Mailing Address - Street 2:#103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-923-0700
Mailing Address - Fax:602-923-0800
Practice Address - Street 1:3229 E GREENWAY RD
Practice Address - Street 2:#103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-923-0700
Practice Address - Fax:602-923-0800
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ502501OtherAHCCESS