Healthcare Provider Details

I. General information

NPI: 1164770491
Provider Name (Legal Business Name): SANAZ IZADI D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 ROCK SPRING RD
FOREST HILL MD
21050-2631
US

IV. Provider business mailing address

212 WASHINGTON AVE APT 1607
TOWSON MD
21204-4734
US

V. Phone/Fax

Practice location:
  • Phone: 410-879-4444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14966
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: