Provider Demographics
NPI:1295878486
Name:HEKMATYAR, MASOUD (DMD)
Entity type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:
Last Name:HEKMATYAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 MONMOUTH ST # A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2637
Mailing Address - Country:US
Mailing Address - Phone:859-581-7678
Mailing Address - Fax:859-581-2624
Practice Address - Street 1:1847 MONMOUTH ST # A
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2637
Practice Address - Country:US
Practice Address - Phone:859-581-7678
Practice Address - Fax:859-581-2624
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60070810Medicaid