Provider Demographics
NPI:1922036516
Name:SHEFAAT, MOHAMMAD REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:REZA
Last Name:SHEFAAT
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 1:9802 RALEIGH TAVERN CT
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2129
Mailing Address - Country:US
Mailing Address - Phone:301-365-0055
Mailing Address - Fax:
Practice Address - Street 1:6000 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3803
Practice Address - Country:US
Practice Address - Phone:301-365-0055
Practice Address - Fax:301-365-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKR83M400Medicare ID - Type Unspecified
MD408622800Medicaid
MDV06562Medicare UPIN