Provider Demographics
NPI:1083853683
Name:MITRI A. GHAREEB, DDS, PC
Entity Type:Organization
Organization Name:MITRI A. GHAREEB, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITRI
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:GHAREEB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-776-4541
Mailing Address - Street 1:5480 BIG TYLER ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313
Mailing Address - Country:US
Mailing Address - Phone:304-776-1212
Mailing Address - Fax:304-776-4542
Practice Address - Street 1:5480 BIG TYLER ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313
Practice Address - Country:US
Practice Address - Phone:304-776-1212
Practice Address - Fax:304-776-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty