=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952990681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FARZAD MOTAMEDI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2021
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 W NORTH AVE
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60160-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-316-2056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 ASHFORD DR APT 733
-----------------------------------------------------
City | WEST MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71291-7853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-428-6572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7160
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7160
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.033940
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------