Healthcare Provider Details

I. General information

NPI: 1194165167
Provider Name (Legal Business Name): AMIR YAVARI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PEACE ST
PROVIDENCE RI
02907
US

IV. Provider business mailing address

3 HARVARD AVE
BROOKLINE MA
02446-6295
US

V. Phone/Fax

Practice location:
  • Phone: 310-866-6687
  • Fax:
Mailing address:
  • Phone: 617-804-0623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN1856651
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: