Healthcare Provider Details

I. General information

NPI: 1104741149
Provider Name (Legal Business Name): NIMA GHORBANI MOGHADDAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N LAKE DR
LEXINGTON SC
29072-2833
US

IV. Provider business mailing address

5800 HIGHLANDS PLAZA DR APT 521
SAINT LOUIS MO
63110-1364
US

V. Phone/Fax

Practice location:
  • Phone: 803-520-3110
  • Fax:
Mailing address:
  • Phone:
  • Fax: 864-762-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11559
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: