Provider Demographics
NPI:1124250824
Name:KHORASHADI, SHAHRZAD (DMD)
Entity type:Individual
Prefix:
First Name:SHAHRZAD
Middle Name:
Last Name:KHORASHADI
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:BOSTON DENTAL
Mailing Address - Street 2:36 CHAUNCY ST
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-338-5000
Mailing Address - Fax:
Practice Address - Street 1:36 CHAUNCY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-2209
Practice Address - Country:US
Practice Address - Phone:617-338-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT100821223G0001X
MADN18552941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice