Healthcare Provider Details

I. General information

NPI: 1851281760
Provider Name (Legal Business Name): AISAN ESKANDARI-YAGHBASTLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SYNDICATE ST N
SAINT PAUL MN
55104-4107
US

IV. Provider business mailing address

111 KELLOGG BLVD E
SAINT PAUL MN
55101-1237
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7373
  • Fax:
Mailing address:
  • Phone: 909-649-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15355
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: