Healthcare Provider Details

I. General information

NPI: 1336112168
Provider Name (Legal Business Name): MAHTAB AZIMI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 E 56TH ST #1D
NEW YORK NY
10022-2432
US

IV. Provider business mailing address

433 E 56TH ST #1D
NEW YORK NY
10022-2432
US

V. Phone/Fax

Practice location:
  • Phone: 212-355-2225
  • Fax: 212-583-1150
Mailing address:
  • Phone: 212-355-2225
  • Fax: 212-583-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number043614
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: