Healthcare Provider Details

I. General information

NPI: 1417732363
Provider Name (Legal Business Name): TANNAZ MALEKZADEH DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 N 51ST AVE STE F650
GLENDALE AZ
85308-5086
US

IV. Provider business mailing address

20100 N 51ST AVE STE F650
GLENDALE AZ
85308-5086
US

V. Phone/Fax

Practice location:
  • Phone: 860-478-6363
  • Fax:
Mailing address:
  • Phone: 860-478-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TANNAZ MALEKZADEH
Title or Position: OWNER
Credential: DMD
Phone: 860-478-6363