Provider Demographics
NPI:1063621746
Name:AMAERI, PEGAH (DMD)
Entity type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:AMAERI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 W PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 MARKET ST
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-5400
Practice Address - Country:US
Practice Address - Phone:201-843-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice