Healthcare Provider Details

I. General information

NPI: 1023480860
Provider Name (Legal Business Name): MEHRAN KHANBABAPOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 S 99TH AVE STE 105
TOLLESON AZ
85353-1404
US

IV. Provider business mailing address

6975 E PRINCESS DR APT 3120
PHOENIX AZ
85054-4234
US

V. Phone/Fax

Practice location:
  • Phone: 623-478-1624
  • Fax:
Mailing address:
  • Phone: 310-991-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2015021512
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD010351
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: