Provider Demographics
NPI:1699173369
Name:FEGHAHATI, HESAM SEYED
Entity type:Individual
Prefix:
First Name:HESAM
Middle Name:SEYED
Last Name:FEGHAHATI
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 1:4125 LAKELAND AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1860
Mailing Address - Country:US
Mailing Address - Phone:763-537-5123
Mailing Address - Fax:763-533-2034
Practice Address - Street 1:4125 LAKELAND AVE N STE 100
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1860
Practice Address - Country:US
Practice Address - Phone:763-537-5123
Practice Address - Fax:763-533-2034
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist