Provider Demographics
NPI:1891342119
Name:MOFRAD, NATASHA (DMD)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MOFRAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29702-9221
Mailing Address - Country:US
Mailing Address - Phone:864-839-0034
Mailing Address - Fax:
Practice Address - Street 1:1119 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:SC
Practice Address - Zip Code:29702-9221
Practice Address - Country:US
Practice Address - Phone:864-839-0034
Practice Address - Fax:864-839-0064
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115491223D0001X, 1223G0001X
SC102461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health