=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598637282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEHRAN MASSOUMI DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2025
-----------------------------------------------------
Last Update Date | 09/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 SHUNPIKE RD UNIT 201
-----------------------------------------------------
City | CROMWELL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06416-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-635-4666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 SHUNPIKE RD UNIT 201
-----------------------------------------------------
City | CROMWELL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06416-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER PLLC
-----------------------------------------------------
Name | MEHRAN MASSAOUMI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 860-635-4666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------