Provider Demographics
NPI:1073654133
Name:GAITHERSBURG DENTAL ASSOCIATE PA
Entity Type:Organization
Organization Name:GAITHERSBURG DENTAL ASSOCIATE PA
Other - Org Name:GITHERSBURG DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANDANA
Authorized Official - Middle Name:GOODARZI
Authorized Official - Last Name:LOGMANNI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-869-2500
Mailing Address - Street 1:8 RUSSELL AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2966
Mailing Address - Country:US
Mailing Address - Phone:301-869-2500
Mailing Address - Fax:301-926-7655
Practice Address - Street 1:8 RUSSELL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2966
Practice Address - Country:US
Practice Address - Phone:301-869-2500
Practice Address - Fax:301-926-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty