Provider Demographics
NPI:1063726255
Name:AHMADZADEH, BIJAN REZA (DMD)
Entity type:Individual
Prefix:DR
First Name:BIJAN
Middle Name:REZA
Last Name:AHMADZADEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 HAMLIN HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-0000
Mailing Address - Country:US
Mailing Address - Phone:570-689-2449
Mailing Address - Fax:866-658-1522
Practice Address - Street 1:358 HAMLIN HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-0000
Practice Address - Country:US
Practice Address - Phone:570-689-2449
Practice Address - Fax:866-658-1522
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist