Provider Demographics
NPI:1720823719
Name:NEZAMABADI, AYSAN (DMD)
Entity type:Individual
Prefix:
First Name:AYSAN
Middle Name:
Last Name:NEZAMABADI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 COURTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1072
Mailing Address - Country:US
Mailing Address - Phone:517-541-8157
Mailing Address - Fax:
Practice Address - Street 1:623 COURTHOUSE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1072
Practice Address - Country:US
Practice Address - Phone:517-541-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016027891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice