Provider Demographics
NPI:1861955809
Name:FARAHANI, MAHSHID AKHAVAN (DDS)
Entity type:Individual
Prefix:
First Name:MAHSHID
Middle Name:AKHAVAN
Last Name:FARAHANI
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 1:322 S MIRALESTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3018
Mailing Address - Country:US
Mailing Address - Phone:816-665-3271
Mailing Address - Fax:
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-633-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1046961223G0001X
MO20210131771223G0001X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty