Healthcare Provider Details

I. General information

NPI: 1205527264
Provider Name (Legal Business Name): ANWAR GEBREMICHAEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RICHLAND MEDICAL PARK DR STE A
COLUMBIA SC
29203-6892
US

IV. Provider business mailing address

9706 BANTING DR
FAIRFAX VA
22032-2453
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6567
  • Fax:
Mailing address:
  • Phone: 301-448-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401418377
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17947
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: