Provider Demographics
NPI:1811189913
Name:GHANBARI, MOHSEN (DDS)
Entity Type:Individual
Prefix:
First Name:MOHSEN
Middle Name:
Last Name:GHANBARI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5727 CENTRE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1916
Mailing Address - Country:US
Mailing Address - Phone:703-803-9200
Mailing Address - Fax:703-803-9419
Practice Address - Street 1:5727 CENTRE SQUARE DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-1916
Practice Address - Country:US
Practice Address - Phone:703-803-9200
Practice Address - Fax:703-803-9419
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist