Basic Information
| Provider Information | |||||||||
| NPI: | 1346448701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANBODAGHI | ||||||||
| FirstName: | AZITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 N BEACON ST | ||||||||
| Address2: | #308 | ||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021341936 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 KNEELAND ST | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021111527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176366971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 04/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21728 | MA | Y | Dental Providers | Dentist | General Practice |
No ID Information.