Provider Demographics
NPI:1366925356
Name:TAEBI-HARANDY, MAHDI (DDS)
Entity type:Individual
Prefix:DR
First Name:MAHDI
Middle Name:
Last Name:TAEBI-HARANDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1956
Mailing Address - Country:US
Mailing Address - Phone:860-679-2000
Mailing Address - Fax:
Practice Address - Street 1:1046 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7144
Practice Address - Country:US
Practice Address - Phone:802-230-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12515390200000X
MADN18591981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103234Medicaid