Provider Demographics
NPI:1205527264
Name:GEBREMICHAEL, ANWAR (DDS)
Entity type:Individual
Prefix:
First Name:ANWAR
Middle Name:
Last Name:GEBREMICHAEL
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 1:9706 BANTING DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2453
Mailing Address - Country:US
Mailing Address - Phone:301-448-5958
Mailing Address - Fax:
Practice Address - Street 1:10 RICHLAND MEDICAL PARK DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6892
Practice Address - Country:US
Practice Address - Phone:803-434-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014183771223G0001X
MD179471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice