Provider Demographics
NPI:1043505365
Name:TAHERIZADEGAN, DONA (DDS)
Entity type:Individual
Prefix:DR
First Name:DONA
Middle Name:
Last Name:TAHERIZADEGAN
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 1:5622 BAZYDLO CT
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3419
Mailing Address - Country:US
Mailing Address - Phone:805-857-1215
Mailing Address - Fax:
Practice Address - Street 1:5622 BAZYDLO CT
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-3419
Practice Address - Country:US
Practice Address - Phone:805-857-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX317811223G0001X, 1223P0221X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program