Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN011636 | GA |
NPI | 1588666309 |
---|---|
Provider Name | Mehrdad Moghaddari |
First Address | Cumming, GA 30041-7488 |
Second Address | Dahlonega, GA 30533-0543 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 08/07/2007 |