Healthcare Provider Details

I. General information

NPI: 1093512584
Provider Name (Legal Business Name): MOHAMMADJAVAD ETESAMI DDS,MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 S COLUMBIA ST
CHAPEL HILL NC
27514-4309
US

IV. Provider business mailing address

404 JONES FERRY RD APT G4
CARRBORO NC
27510-2043
US

V. Phone/Fax

Practice location:
  • Phone: 240-654-7896
  • Fax:
Mailing address:
  • Phone: 240-654-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number151468
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: