Provider Demographics
NPI:1558053785
Name:MIRMOTAHARI, MITRA
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:MIRMOTAHARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 SAUNDERS TAVERN TRL UNIT B
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7816
Mailing Address - Country:US
Mailing Address - Phone:804-874-0440
Mailing Address - Fax:
Practice Address - Street 1:684 BATTLEFIELD BLVD N STE A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5037
Practice Address - Country:US
Practice Address - Phone:757-319-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418415122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist