MEDICARE: ARDESHIR TAHERI-TAFRESHI DMD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	054824	NY

General Provider Information

NPI Number	:	1790090272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARDESHIR TAHERI-TAFRESHI DMD, INC.

Provider Business Mailing Address
First Line	:	3200 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6723
Country	:	US
Telephone Number	:	718-761-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6723
Country	:	US
Telephone Number	:	718-761-3200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ARDESHIR TAHERI-TAFRESHI
Credential	:	DMD
Telephone Number	:	718-761-3200

Provider Enumeration Date	:	08/09/2010
Last Update Date	:	10/27/2014

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