Provider Demographics
NPI:1952157356
Name:MOGHADDAM, MAHSA (DMD)
Entity type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 QUEENSBERRY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5006
Mailing Address - Country:US
Mailing Address - Phone:413-356-0949
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:617-358-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADL1003191223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program