Provider Demographics
NPI:1023845542
Name:MANOOCHEHRI, SOGOL
Entity type:Individual
Prefix:
First Name:SOGOL
Middle Name:
Last Name:MANOOCHEHRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E EDSALL BLVD
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2336
Mailing Address - Country:US
Mailing Address - Phone:908-821-5848
Mailing Address - Fax:
Practice Address - Street 1:460 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2919
Practice Address - Country:US
Practice Address - Phone:201-608-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22HI01090500124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist