Provider Demographics
NPI:1730121468
Name:MODARRES, SHAHRAM
Entity Type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:MODARRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5822 HUBBARD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4818
Mailing Address - Country:US
Mailing Address - Phone:301-816-9400
Mailing Address - Fax:301-770-9263
Practice Address - Street 1:5822 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4818
Practice Address - Country:US
Practice Address - Phone:301-816-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist