Provider Demographics
NPI:1699263541
Name:AMIRI-HEZAVEH, POUYA (DMD)
Entity type:Individual
Prefix:
First Name:POUYA
Middle Name:
Last Name:AMIRI-HEZAVEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 HOPE AVE APT 515
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-4701
Mailing Address - Country:US
Mailing Address - Phone:781-820-2173
Mailing Address - Fax:
Practice Address - Street 1:530 BOSTON POST RD E
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3645
Practice Address - Country:US
Practice Address - Phone:585-481-8094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18584631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty