Healthcare Provider Details

I. General information

NPI: 1902633696
Provider Name (Legal Business Name): IFACE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 BRIDLE PATH
MARIETTA GA
30068-4911
US

IV. Provider business mailing address

407 BRIDLE PATH
MARIETTA GA
30068-4911
US

V. Phone/Fax

Practice location:
  • Phone: 954-376-2412
  • Fax:
Mailing address:
  • Phone: 954-376-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHOHREH GHASEMI
Title or Position: OWNER
Credential: MD
Phone: 954-376-2412