MEDICARE: NEDA RAEISIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN013263	GA

General Provider Information

NPI Number	:	1174625768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEDA RAEISIAN

Provider Business Mailing Address
First Line	:	2502 N ROCKY POINT DR
Second Line	:	SUITE 1000-CREDENTIALING
City	:	TAMPA
State	:	FL
Zip	:	33607-1421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 PLEASANT HILL RD
Second Line	:	SUITE 200
City	:	DULUTH
State	:	GA
Zip	:	30096-5899
Country	:	US
Telephone Number	:	770-381-7878
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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Directions to “ NEDA RAEISIAN ” Practice Location

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