Provider Demographics
NPI:1912736851
Name:EDALATI SHARBAF, AHMAD REZA
Entity type:Individual
Prefix:
First Name:AHMAD REZA
Middle Name:
Last Name:EDALATI SHARBAF
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 1:6468 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-2160
Mailing Address - Country:US
Mailing Address - Phone:916-294-5214
Mailing Address - Fax:
Practice Address - Street 1:3701 WILLIAMS BLVD STE 253
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3067
Practice Address - Country:US
Practice Address - Phone:504-469-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-1131223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics