=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871668137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOUSHIN NASRI-GHAJARI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CHILDREN DENTISTRY OF LODI 170 MAIN STREET UNITS 109-110
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-397-1420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 ALPINE DR
-----------------------------------------------------
City | CLOSTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07624-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-741-9565
-----------------------------------------------------
Fax | 201-302-9845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 19447
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------