Provider Demographics
NPI:1952994600
Name:HADERA, YOHANNES GHIRMAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:YOHANNES
Middle Name:GHIRMAY
Last Name:HADERA
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 1:8445 N 23RD AVE APT 165
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4815
Mailing Address - Country:US
Mailing Address - Phone:602-509-8741
Mailing Address - Fax:
Practice Address - Street 1:420 W WATKINS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2830
Practice Address - Country:US
Practice Address - Phone:602-254-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX381071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice