Provider Demographics
NPI:1447669171
Name:AFSARI, NIMA
Entity type:Individual
Prefix:DR
First Name:NIMA
Middle Name:
Last Name:AFSARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROSSANLEY DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1713
Mailing Address - Country:US
Mailing Address - Phone:541-779-4799
Mailing Address - Fax:
Practice Address - Street 1:11 ROSSANLEY DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1713
Practice Address - Country:US
Practice Address - Phone:541-779-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA637411223G0001X
ORD101481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice