Provider Demographics
NPI:1063148633
Name:MONFAREDZADEH, MORVARID (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MORVARID
Middle Name:
Last Name:MONFAREDZADEH
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 STATION BLVD APT 414
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4449
Mailing Address - Country:US
Mailing Address - Phone:331-529-4158
Mailing Address - Fax:
Practice Address - Street 1:2041 FIFTEENTH MILE ROAD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4831
Practice Address - Country:US
Practice Address - Phone:586-268-0900
Practice Address - Fax:586-268-3766
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337551223P0300X
MI29016015651223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty