Healthcare Provider Details

I. General information

NPI: 1467468702
Provider Name (Legal Business Name): SHOKOUFEH EMAMIAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 PENN AVE FORUM DENTAL ASSOCIATES PC
SCRANTON PA
18503
US

IV. Provider business mailing address

247 PENN AVE FORUM DENTAL ASSOCIATES PC
SCRANTON PA
18503
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-0643
  • Fax:
Mailing address:
  • Phone: 570-343-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS029199L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: