Provider Demographics
NPI:1194900100
Name:MOFIDI, MAHYAR (DMD)
Entity type:Individual
Prefix:DR
First Name:MAHYAR
Middle Name:
Last Name:MOFIDI
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 1:1832 BILTMORE ST NW
Mailing Address - Street 2:#23
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-1963
Mailing Address - Country:US
Mailing Address - Phone:202-246-9191
Mailing Address - Fax:
Practice Address - Street 1:1480 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210
Practice Address - Country:US
Practice Address - Phone:502-778-7414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist