Provider Demographics
NPI:1578636510
Name:GHOZATI, SHADI (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:
Last Name:GHOZATI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7226 LEE DEFORST DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046
Mailing Address - Country:US
Mailing Address - Phone:410-872-0103
Mailing Address - Fax:410-872-0105
Practice Address - Street 1:7226 LEE DEFOREST RD
Practice Address - Street 2:SUITE 208
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3235
Practice Address - Country:US
Practice Address - Phone:410-872-0103
Practice Address - Fax:410-872-0105
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice