Provider Demographics
NPI:1982997177
Name:EMAM, AZADEH (DMD)
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:EMAM
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 1:55 SACK BLVD
Mailing Address - Street 2:UNIT 5
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3325
Mailing Address - Country:US
Mailing Address - Phone:857-277-3077
Mailing Address - Fax:
Practice Address - Street 1:55 SACK BLVD
Practice Address - Street 2:UNIT 5
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3325
Practice Address - Country:US
Practice Address - Phone:978-466-6800
Practice Address - Fax:978-466-6801
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855565122300000X
IL019028489122300000X
TX0025956122300000X
CT10358122300000X
IN12011534A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist