Provider Demographics
NPI:1679812093
Name:KHASHAYAR, GHAZAL (DMD, PHD, MSC)
Entity type:Individual
Prefix:DR
First Name:GHAZAL
Middle Name:
Last Name:KHASHAYAR
Suffix:
Gender:F
Credentials:DMD, PHD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-2702
Mailing Address - Country:US
Mailing Address - Phone:203-628-2077
Mailing Address - Fax:
Practice Address - Street 1:124 BROAD ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-2702
Practice Address - Country:US
Practice Address - Phone:203-628-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0116701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice