Provider Demographics
NPI:1467485599
Name:BROUMAND, VISHTASB (DMD MD)
Entity type:Individual
Prefix:
First Name:VISHTASB
Middle Name:
Last Name:BROUMAND
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20950 N TATUM BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4269
Mailing Address - Country:US
Mailing Address - Phone:480-284-8087
Mailing Address - Fax:480-659-6098
Practice Address - Street 1:20950 N TATUM BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4269
Practice Address - Country:US
Practice Address - Phone:480-284-8087
Practice Address - Fax:480-659-6098
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008845122300000X, 1223S0112X
FLDN145331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist