Provider Demographics
NPI:1164440608
Name:IZADIDEHKORDI, MOHAMMAD - (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:-
Last Name:IZADIDEHKORDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:-
Other - Last Name:IZADI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:11400 LAKE POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1216
Mailing Address - Country:US
Mailing Address - Phone:301-983-0818
Mailing Address - Fax:301-983-0650
Practice Address - Street 1:12209 TULLAMORE RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-7816
Practice Address - Country:US
Practice Address - Phone:410-560-0360
Practice Address - Fax:410-560-0364
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110801223X0400X
VA04010080061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics