Provider Demographics
NPI:1720497183
Name:GHADAKZADEH, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GHADAKZADEH
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 1:750 NW 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-4618
Mailing Address - Country:US
Mailing Address - Phone:305-325-0510
Mailing Address - Fax:
Practice Address - Street 1:750 NW 20TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-4618
Practice Address - Country:US
Practice Address - Phone:305-325-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice