Provider Demographics
NPI:1619497989
Name:ADHAMI, MITRA DARICE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:DARICE
Last Name:ADHAMI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 FLAG CIR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-4917
Mailing Address - Country:US
Mailing Address - Phone:256-479-8490
Mailing Address - Fax:
Practice Address - Street 1:1821 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-801-0039
Practice Address - Fax:866-803-4943
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty