Healthcare Provider Details

I. General information

NPI: 1881744563
Provider Name (Legal Business Name): KHOSROW BENJAMIN AZIZI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BENJAMIN K AZIZI D.M.D.

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 N KESWICK AVE
GLENSIDE PA
19038-4804
US

IV. Provider business mailing address

242 N KESWICK AVE
GLENSIDE PA
19038-4804
US

V. Phone/Fax

Practice location:
  • Phone: 215-576-6414
  • Fax: 215-576-8497
Mailing address:
  • Phone: 215-576-6414
  • Fax: 215-576-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS025908L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: