Provider Demographics
NPI:1417528423
Name:GHORBANI, JALIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JALIL
Middle Name:
Last Name:GHORBANI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 N PARK AVE APT 805
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-4430
Mailing Address - Country:US
Mailing Address - Phone:920-242-1947
Mailing Address - Fax:
Practice Address - Street 1:5271 S CALLE SANTA CRUZ STE 181
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-3561
Practice Address - Country:US
Practice Address - Phone:520-889-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0111061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice