Provider Demographics
NPI:1588337364
Name:TAGHIZADEH, SHADBEH N
Entity type:Individual
Prefix:
First Name:SHADBEH
Middle Name:N
Last Name:TAGHIZADEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CAMBRIDGE PKWY UNIT E511
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1239
Mailing Address - Country:US
Mailing Address - Phone:339-223-0774
Mailing Address - Fax:
Practice Address - Street 1:302 BROADWAY STE 6&7
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1439
Practice Address - Country:US
Practice Address - Phone:508-880-5891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859125122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist