Provider Demographics
NPI:1407365703
Name:ZOHREHEI, HEIDAR
Entity type:Individual
Prefix:
First Name:HEIDAR
Middle Name:
Last Name:ZOHREHEI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 MYSTIC VALLEY PKWY APT 109
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6900
Mailing Address - Country:US
Mailing Address - Phone:978-483-1565
Mailing Address - Fax:
Practice Address - Street 1:160 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1529
Practice Address - Country:US
Practice Address - Phone:781-593-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18577631223E0200X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist