Basic Information
| Provider Information | |||||||||
| NPI: | 1760545164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRAJ | ||||||||
| FirstName: | RAHA | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | OPEN DOOR FAMILY MEDICAL CENTERS, INC. | ||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149411263 | ||||||||
| FaxNumber: | 9149410993 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 GRACE CHURCH ST | ||||||||
| Address2: | OPEN DOOR FAMILY MEDICAL CENTERS, INC. | ||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105734911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149378899 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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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 | 122300000X | 049847-1 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 02746216 | 05 | NY | MEDICAID |