Provider Demographics
NPI:1699732602
Name:HOSSAINIZADEH, MEHRAN (DMD)
Entity type:Individual
Prefix:MR
First Name:MEHRAN
Middle Name:
Last Name:HOSSAINIZADEH
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:PO BOX 824635
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4635
Mailing Address - Country:US
Mailing Address - Phone:215-707-2912
Mailing Address - Fax:215-707-5885
Practice Address - Street 1:3223 N. BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-7756
Practice Address - Fax:215-707-5885
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA533691223S0112X
PADA030545R1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU72186Medicare UPIN