Provider Demographics
NPI:1598373383
Name:REZAEI BOROUN, ATEFEH
Entity Type:Individual
Prefix:
First Name:ATEFEH
Middle Name:
Last Name:REZAEI BOROUN
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 1:113 ELLINGTON BLVD APT 417
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4529
Mailing Address - Country:US
Mailing Address - Phone:703-984-9903
Mailing Address - Fax:
Practice Address - Street 1:13600 BALTIMORE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9495
Practice Address - Country:US
Practice Address - Phone:301-470-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics