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General NPI Number Information
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NPI Number | 1447630488
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Entity Type | Individual
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Provider Name | MRS. AZITA EBRAHIMZADEH
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Gender | Female
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 06/04/2015
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Provider Practice Location Address
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Address Line | 291 MOUNTAIN AVE
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City | SPRINGFIELD
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State | NJ
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Zip | 07081-2214
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Country | US
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Telephone | 973-901-2322
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Fax |
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Provider Business Mailing Address
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Address Line | 291 MOUNTAIN AVE
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City | SPRINGFIELD
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State | NJ
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Zip | 07081-2214
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Country | US
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Telephone | 973-901-2322
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | E10630710056822
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License Number State | NJ
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