Healthcare Provider Details

I. General information

NPI: 1184128688
Provider Name (Legal Business Name): NIMA MOAVEN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 10/02/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20950 N TATUM BLVD STE 210
PHOENIX AZ
85050-4268
US

IV. Provider business mailing address

20950 N TATUM BLVD STE 210
PHOENIX AZ
85050-4268
US

V. Phone/Fax

Practice location:
  • Phone: 480-538-8100
  • Fax:
Mailing address:
  • Phone: 480-538-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD011390
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD011390
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: