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General NPI Number Information
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NPI Number | 1336693910
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Entity Type | Individual
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Provider Name | MOHAMMAD REZA TABATABAI IRANI DDS
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Gender | Male
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Dates
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Enumeration Date | 08/11/2016
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Last Update Date | 08/11/2016
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Provider Practice Location Address
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Address Line | 446 S MAIN ST
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City | NEW BRITAIN
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State | CT
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Zip | 06051-3516
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Country | US
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Telephone | 860-225-0552
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Fax |
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Provider Business Mailing Address
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Address Line | 475 MAIN ST APT 2R
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City | NEW YORK
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State | NY
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Zip | 10044-0084
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Country | US
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Telephone | 949-300-3631
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 11704
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License Number State | CT
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