Healthcare Provider Details

I. General information

NPI: 1578658076
Provider Name (Legal Business Name): FARHAD MOSHIRI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY 501 S. PRESTON ST.
LOUISVILLE KY
40292
US

IV. Provider business mailing address

UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY 501 S. PRESTON ST.
LOUISVILLE KY
40292
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5128
  • Fax: 502-852-7163
Mailing address:
  • Phone: 502-852-5128
  • Fax: 502-852-7163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6062
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: