Provider Demographics
NPI:1588666309
Name:MOGHADDARI, MEHRDAD (DDS)
Entity Type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:MOGHADDARI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 GENTRY WALK CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7488
Mailing Address - Country:US
Mailing Address - Phone:404-457-3538
Mailing Address - Fax:
Practice Address - Street 1:56A SHORT ST
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-0543
Practice Address - Country:US
Practice Address - Phone:706-867-2727
Practice Address - Fax:706-867-2739
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0116361223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health