Provider Demographics
NPI:1184635484
Name:MOGHADDAM, FARID (DMD)
Entity Type:Individual
Prefix:DR
First Name:FARID
Middle Name:
Last Name:MOGHADDAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 FRIENDSHIP CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6918
Mailing Address - Country:US
Mailing Address - Phone:678-860-9911
Mailing Address - Fax:
Practice Address - Street 1:1715 FRIENDSHIP CIR STE 100
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-6918
Practice Address - Country:US
Practice Address - Phone:678-860-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist