Provider Demographics
NPI:1932758505
Name:GHORBANIFARAJZADEH, MINA (DMD)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:GHORBANIFARAJZADEH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:GHORBANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1920 NE 210TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-1521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 W 41ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-3413
Practice Address - Country:US
Practice Address - Phone:305-672-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24114261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental