Provider Demographics
NPI:1497716096
Name:GHAJARNIA, M. REZA (DMD)
Entity Type:Individual
Prefix:
First Name:M. REZA
Middle Name:
Last Name:GHAJARNIA
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 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1286 MARYLAND RT 3 S STE 7
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1340
Practice Address - Country:US
Practice Address - Phone:410-721-8200
Practice Address - Fax:410-721-7629
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035239122300000X, 1223X0400X
MD143781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019078380001Medicaid