Provider Demographics
NPI:1801939111
Name:DARJ, MEHRNOOSH (DDS)
Entity type:Individual
Prefix:DR
First Name:MEHRNOOSH
Middle Name:
Last Name:DARJ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1861 ROBERT WYNN ST STE D
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4255
Mailing Address - Country:US
Mailing Address - Phone:908-405-8199
Mailing Address - Fax:915-595-6693
Practice Address - Street 1:1861 ROBERT WYNN ST
Practice Address - Street 2:SUITED
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4254
Practice Address - Country:US
Practice Address - Phone:908-696-9225
Practice Address - Fax:915-595-6693
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02061600122300000X
NY048641122300000X
TX0023061122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7960701Medicaid