MEDICARE: BROOKE MAHDAVI DMD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN015346	GA

General Provider Information

NPI Number	:	1184283111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE MAHDAVI DMD

Provider Business Mailing Address
First Line	:	55 CHESTER AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-1201
Country	:	US
Telephone Number	:	239-940-0867
Fax Number	:

Provider Business Practice Location Address
First Line	:	955 MEMORIAL DR SE STE 530
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-1566
Country	:	US
Telephone Number	:	770-800-5802
Fax Number	:

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

Provider Enumeration Date	:	06/12/2019
Last Update Date	:	03/12/2023

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