Provider Demographics
NPI:1629236518
Name:RADFAR, SHAHLA ROGHIEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:ROGHIEH
Last Name:RADFAR
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 1:5052 DORSEY HALL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7750
Mailing Address - Country:US
Mailing Address - Phone:410-772-9552
Mailing Address - Fax:410-772-9554
Practice Address - Street 1:5052 DORSEY HALL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7750
Practice Address - Country:US
Practice Address - Phone:410-772-9552
Practice Address - Fax:410-772-9554
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist