Provider Demographics
NPI:1982149522
Name:GHORBANI - MOHAMMADI DENTAL P.C.
Entity type:Organization
Organization Name:GHORBANI - MOHAMMADI DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:GHORBANI-MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-313-3228
Mailing Address - Street 1:2676 E MAIN ST
Mailing Address - Street 2:COLUMBIA DENTAL
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2676 E MAIN ST
Practice Address - Street 2:COLUMBIA DENTAL
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1422
Practice Address - Country:US
Practice Address - Phone:408-313-3228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11154122300000X
CT8514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty