Provider Demographics
NPI:1356652739
Name:MOADDAB, MOHAMMAD (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:MOADDAB
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 IPSWICH RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1809
Mailing Address - Country:US
Mailing Address - Phone:202-543-8110
Mailing Address - Fax:
Practice Address - Street 1:5905 IPSWICH RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1809
Practice Address - Country:US
Practice Address - Phone:202-543-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN42451223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice