Provider Demographics
NPI:1528567575
Name:DR. MASSOUD EFTEKHARI
Entity type:Organization
Organization Name:DR. MASSOUD EFTEKHARI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MASSOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:EFTEKHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-430-8462
Mailing Address - Street 1:14524 N 106TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-8595
Mailing Address - Country:US
Mailing Address - Phone:602-430-8462
Mailing Address - Fax:928-634-1363
Practice Address - Street 1:830 S MAIN ST STE 1D
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4621
Practice Address - Country:US
Practice Address - Phone:928-634-5566
Practice Address - Fax:928-634-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1659524692OtherNPI INDIVIDUAL
AZ496932Medicaid
AZ4954OtherDENTAL LICENSE