Provider Demographics
NPI:1952716003
Name:DEZFOOLIAN, ROSHANAK (DMD)
Entity type:Individual
Prefix:DR
First Name:ROSHANAK
Middle Name:
Last Name:DEZFOOLIAN
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 1:120 LITTLE FOX LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 CHASE PKWY STE 2A
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3163
Practice Address - Country:US
Practice Address - Phone:203-757-1455
Practice Address - Fax:203-757-2953
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid