Healthcare Provider Details

I. General information

NPI: 1982637922
Provider Name (Legal Business Name): A REZA MIREMADI M.D., DDS., LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 N MAIN ST
SPRINGBORO OH
45066-9552
US

IV. Provider business mailing address

576 N MAIN ST
SPRINGBORO OH
45066-9552
US

V. Phone/Fax

Practice location:
  • Phone: 937-748-8814
  • Fax: 937-748-8817
Mailing address:
  • Phone: 937-748-8814
  • Fax: 937-748-8817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number21379
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number79671
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: