Provider Demographics
NPI:1932809191
Name:AMDANI, AFSHA
Entity type:Individual
Prefix:
First Name:AFSHA
Middle Name:
Last Name:AMDANI
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 1:5210 CLARO DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-7322
Mailing Address - Country:US
Mailing Address - Phone:203-945-7939
Mailing Address - Fax:
Practice Address - Street 1:1411 W LANE RD STE B
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-1661
Practice Address - Country:US
Practice Address - Phone:708-345-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0340131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice