Provider Demographics
NPI:1720366099
Name:DAVALLOO-GHAJAR, HASSAN
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:DAVALLOO-GHAJAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20111 CIDER BARREL DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-2708
Mailing Address - Country:US
Mailing Address - Phone:954-829-5552
Mailing Address - Fax:240-654-4743
Practice Address - Street 1:20111 CIDER BARREL DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-2708
Practice Address - Country:US
Practice Address - Phone:954-829-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist