Healthcare Provider Details

I. General information

NPI: 1215670161
Provider Name (Legal Business Name): VANA GHAZY BAHRAM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 09/03/2022
Certification Date: 09/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PITTS SCHOOL RD SW
CONCORD NC
28027-3931
US

IV. Provider business mailing address

6025 RUISSEAU ST UNIT 1407
CHARLOTTE NC
28269-3668
US

V. Phone/Fax

Practice location:
  • Phone: 704-461-0707
  • Fax:
Mailing address:
  • Phone: 214-864-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38874
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12987
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: