Healthcare Provider Details

I. General information

NPI: 1245755776
Provider Name (Legal Business Name): TIA KHOSHABA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2017
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 W BETHANY HOME RD
PHOENIX AZ
85015-1850
US

IV. Provider business mailing address

6127 E HORSESHOE RD
PARADISE VALLEY AZ
85253-2264
US

V. Phone/Fax

Practice location:
  • Phone: 602-841-7548
  • Fax: 602-481-7556
Mailing address:
  • Phone: 480-840-4098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD009849
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: