Provider Demographics
NPI:1285948448
Name:ROSTAMI, MAHSA (DMD)
Entity type:Individual
Prefix:DR
First Name:MAHSA
Middle Name:
Last Name:ROSTAMI
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 1:200 BARTRAM MARKET DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4579
Mailing Address - Country:US
Mailing Address - Phone:904-671-8502
Mailing Address - Fax:
Practice Address - Street 1:200 BARTRAM MARKET DR
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4579
Practice Address - Country:US
Practice Address - Phone:904-671-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice