Healthcare Provider Details

I. General information

NPI: 1548955461
Provider Name (Legal Business Name): ALEXANDRA YAZDANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W BANKHEAD HWY
VILLA RICA GA
30180-1702
US

IV. Provider business mailing address

10001 CHESTER AVE APT 621
CLEVELAND OH
44106-1639
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-2550
  • Fax:
Mailing address:
  • Phone: 905-251-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123398
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: