Provider Demographics
NPI:1700144714
Name:GHORBANI-MOGHADDAM, HAMED (DDS)
Entity Type:Individual
Prefix:DR
First Name:HAMED
Middle Name:
Last Name:GHORBANI-MOGHADDAM
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 1:2690 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:COLUMBIA DENTAL
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
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT111541223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice