MEDICARE: PAYAM MIRFENDERESKI

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	125Q00000X	Oral Medicine Dentistry	063834	NY
2	122300000X	Dentist	106713	CA
3	122300000X	Dentist	063834	NY

General Provider Information

NPI Number	:	1912584764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAYAM MIRFENDERESKI

Provider Business Mailing Address
First Line	:	345 E 24TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-4020
Country	:	US
Telephone Number	:	212-998-9743
Fax Number	:	212-995-4767

Provider Business Practice Location Address
First Line	:	345 E 24TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-4020
Country	:	US
Telephone Number	:	212-998-9743
Fax Number	:	212-995-4767

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

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	05/28/2024

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Directions to “ PAYAM MIRFENDERESKI ” Practice Location

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