Healthcare Provider Details

I. General information

NPI: 1073583639
Provider Name (Legal Business Name): MITRA HEDAYETI VAHDANI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6188 OXON HILL RD 2ND FLOOR
OXON HILL MD
20745-3113
US

IV. Provider business mailing address

6188 OXON HILL RD 2ND FLOOR
OXON HILL MD
20745-3113
US

V. Phone/Fax

Practice location:
  • Phone: 301-567-3122
  • Fax: 301-567-5234
Mailing address:
  • Phone: 301-567-3122
  • Fax: 301-567-5234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12938
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: