Provider Demographics
NPI:1730424771
Name:POURANFAR, FARZAN LEONARDO (DMD)
Entity type:Individual
Prefix:DR
First Name:FARZAN
Middle Name:LEONARDO
Last Name:POURANFAR
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:BAUMHOLDER DENTAL CLINIC
Mailing Address - Street 2:8647 SMITH BARRACKS
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BAUMHOLDER DENTAL CLINIC
Practice Address - Street 2:8647 SMITH BARRACKS
Practice Address - City:BAUMHOLDER
Practice Address - State:REILANDFALS
Practice Address - Zip Code:09034
Practice Address - Country:DE
Practice Address - Phone:149-458-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice