Provider Demographics
NPI:1851281760
Name:ESKANDARI-YAGHBASTLO, AISAN
Entity type:Individual
Prefix:
First Name:AISAN
Middle Name:
Last Name:ESKANDARI-YAGHBASTLO
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 1:111 KELLOGG BLVD E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1237
Mailing Address - Country:US
Mailing Address - Phone:909-649-8636
Mailing Address - Fax:
Practice Address - Street 1:450 SYNDICATE ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4107
Practice Address - Country:US
Practice Address - Phone:651-254-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty