Healthcare Provider Details

I. General information

NPI: 1356993729
Provider Name (Legal Business Name): AMIR VAHDANI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 NEEL AVE
SOCORRO NM
87801-4649
US

IV. Provider business mailing address

6129 ROSETREE PL NE
ALBUQUERQUE NM
87111-7201
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-1623
  • Fax:
Mailing address:
  • Phone: 202-420-1801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5170
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: