Provider Demographics
NPI:1144429259
Name:GHARAGOZLOO, MARY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:GHARAGOZLOO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338-A NORTH MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801
Mailing Address - Country:US
Mailing Address - Phone:407-648-3688
Mailing Address - Fax:407-648-8306
Practice Address - Street 1:338-A NORTH MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801
Practice Address - Country:US
Practice Address - Phone:407-648-3688
Practice Address - Fax:407-648-8306
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist