Healthcare Provider Details

I. General information

NPI: 1699732602
Provider Name (Legal Business Name): MEHRAN HOSSAINIZADEH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N. BROAD STREET
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

PO BOX 824635
PHILADELPHIA PA
19182-4635
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-7756
  • Fax: 215-707-5885
Mailing address:
  • Phone: 215-707-2912
  • Fax: 215-707-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53369
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDA030545R
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: