Basic Information
| Provider Information | |||||||||
| NPI: | 1811220197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAMVARI | ||||||||
| FirstName: | BEHNAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203641429 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Practice Location | |||||||||
| Address1: | 10566 N HIGHWAY 191 | ||||||||
| Address2: | |||||||||
| City: | ELFRIDA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856109021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206422222 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 09/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7893 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 468656 | 05 | AZ | MEDICAID |