MEDICARE: REZA HADIOONZADEH DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12976	TN
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	11076	KY

General Provider Information

NPI Number	:	1346892734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REZA HADIOONZADEH DDS

Provider Business Mailing Address
First Line	:	3039 32ND ST APT 2B
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-2083
Country	:	US
Telephone Number	:	518-421-2627
Fax Number	:

Provider Business Practice Location Address
First Line	:	4919 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-4051
Country	:	US
Telephone Number	:	518-421-2627
Fax Number	:

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

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	04/21/2026

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