Provider Demographics
NPI:1053756205
Name:BAKHSHOUDEH, BOBAK
Entity type:Individual
Prefix:
First Name:BOBAK
Middle Name:
Last Name:BAKHSHOUDEH
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 1:308 E 38TH ST APT 6D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-9821
Mailing Address - Country:US
Mailing Address - Phone:631-880-2208
Mailing Address - Fax:
Practice Address - Street 1:25 TUDOR CITY PL
Practice Address - Street 2:APT 2122
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6819
Practice Address - Country:US
Practice Address - Phone:631-880-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057492-1122300000X, 1223E0200X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program