Provider Demographics
NPI:1043615511
Name:GHANEH, GHAZALEH
Entity Type:Individual
Prefix:
First Name:GHAZALEH
Middle Name:
Last Name:GHANEH
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 1:2001 HOLCOMBE BLVD
Mailing Address - Street 2:UNIT 2905
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7500 CAMBRIDGE ST
Practice Address - Street 2:SUITE 6400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2032
Practice Address - Country:US
Practice Address - Phone:713-382-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX304411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics