MEDICARE: FARNOSH MOJTABAEE 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	1223G0001X	General Practice Dentistry	35410	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35410	OTHER	TX	TEXAS STATE BOARD OF DENTAL EXAMINERS

General Provider Information

NPI Number	:	1528611019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARNOSH MOJTABAEE DDS

Provider Business Mailing Address
First Line	:	3024 SHANE DR
Second Line	:
City	:	LEANDER
State	:	TX
Zip	:	78641-4500
Country	:	US
Telephone Number	:	512-905-6582
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 W PARMER LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78727-4501
Country	:	US
Telephone Number	:	512-251-6125
Fax Number	:

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

Provider Enumeration Date	:	07/23/2019
Last Update Date	:	07/23/2019

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