Provider Demographics
NPI:1659582187
Name:HUSHANG GHODRAT DDS, PA
Entity Type:Organization
Organization Name:HUSHANG GHODRAT DDS, PA
Other - Org Name:BUTNER CREEDMOOR FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANGAER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUMMITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-528-9500
Mailing Address - Street 1:2552 CAPITOL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-9451
Mailing Address - Country:US
Mailing Address - Phone:919-528-9500
Mailing Address - Fax:919-528-9556
Practice Address - Street 1:2552 CAPITOL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-9451
Practice Address - Country:US
Practice Address - Phone:919-528-9500
Practice Address - Fax:919-528-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900569Medicaid