Provider Demographics
NPI:1831717180
Name:ELGHANNAM, MOHAMED M (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:M
Last Name:ELGHANNAM
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 1:220 W BRAMBLETON AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1571
Mailing Address - Country:US
Mailing Address - Phone:757-583-1536
Mailing Address - Fax:757-583-3470
Practice Address - Street 1:220 W BRAMBLETON AVE STE 111
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1571
Practice Address - Country:US
Practice Address - Phone:757-583-1536
Practice Address - Fax:757-583-3470
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014177401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty