MEDICARE: DR. ATEFEH MOSTAVI 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	122300000X	Dentist	2901020766	MI

General Provider Information

NPI Number	:	1689939357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ATEFEH MOSTAVI DDS

Provider Business Mailing Address
First Line	:	430 W ERIE ST STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-6920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 W PIERSON RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-6802
Country	:	US
Telephone Number	:	810-789-5880
Fax Number	:

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

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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