Provider Demographics
NPI:1508091687
Name:SHADI GHOZATI D.D.S. PA
Entity Type:Organization
Organization Name:SHADI GHOZATI D.D.S. PA
Other - Org Name:COLUMBIA GATEWAY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIS/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHADI
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOZATI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-872-0104
Mailing Address - Street 1:7226 LEE DEFOREST DR
Mailing Address - Street 2:#208
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3239
Mailing Address - Country:US
Mailing Address - Phone:410-872-0104
Mailing Address - Fax:410-872-0105
Practice Address - Street 1:7226 LEE DEFOREST DR
Practice Address - Street 2:#208
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3239
Practice Address - Country:US
Practice Address - Phone:410-872-0104
Practice Address - Fax:410-872-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty