Provider Demographics
NPI:1083308373
Name:KIANMAJD, FARIBA
Entity type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:KIANMAJD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 CITY PLACE BLVD UNIT 2325
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-5518
Mailing Address - Country:US
Mailing Address - Phone:916-945-6144
Mailing Address - Fax:
Practice Address - Street 1:709 RODEO DR STE 114
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7758
Practice Address - Country:US
Practice Address - Phone:716-386-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND149631223G0001X
WI600167115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice