Provider Demographics
NPI:1821503210
Name:MGM FAMILY DENTAL
Entity Type:Organization
Organization Name:MGM FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:GHORBANI-MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-612-6079
Mailing Address - Street 1:2690 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1422
Mailing Address - Country:US
Mailing Address - Phone:203-612-6079
Mailing Address - Fax:203-612-6081
Practice Address - Street 1:2690 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1422
Practice Address - Country:US
Practice Address - Phone:203-612-6079
Practice Address - Fax:203-612-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11154261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental