Provider Demographics
NPI:1912166141
Name:DR. FARDAD MOBED, P.C.
Entity type:Organization
Organization Name:DR. FARDAD MOBED, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOBED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-289-3600
Mailing Address - Street 1:603 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3045
Mailing Address - Country:US
Mailing Address - Phone:781-289-3600
Mailing Address - Fax:
Practice Address - Street 1:603 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3045
Practice Address - Country:US
Practice Address - Phone:781-289-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181871223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty