Provider Demographics
NPI:1477745396
Name:BARADARAN, EBRAHIM H (DMD)
Entity Type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:H
Last Name:BARADARAN
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 1:100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-1242
Mailing Address - Country:US
Mailing Address - Phone:804-651-1515
Mailing Address - Fax:540-955-4158
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22611-1242
Practice Address - Country:US
Practice Address - Phone:804-651-1515
Practice Address - Fax:540-955-4158
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist