Provider Demographics
NPI:1366751364
Name:KHALATBARI, MANDANA (DDS)
Entity type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:KHALATBARI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WATERSIDE PLZ
Mailing Address - Street 2:#9K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2602
Mailing Address - Country:US
Mailing Address - Phone:646-284-4746
Mailing Address - Fax:718-367-4244
Practice Address - Street 1:86 W 183RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-1212
Practice Address - Country:US
Practice Address - Phone:718-367-4222
Practice Address - Fax:718-367-4244
Is Sole Proprietor?:No
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055251-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist