Healthcare Provider Details

I. General information

NPI: 1306407994
Provider Name (Legal Business Name): KAMBIZ VATANDOOST DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

75 W END AVE APT P8D
NEW YORK NY
10023-7871
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5690
  • Fax:
Mailing address:
  • Phone: 646-709-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number061129-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: