Healthcare Provider Details

I. General information

NPI: 1821165812
Provider Name (Legal Business Name): MITRI A GHAREEB D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/07/2023
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 CROSS LANES DR
CROSS LANES WV
25313-1334
US

IV. Provider business mailing address

5480 BIG TYLER RD STE 1
CROSS LANES WV
25313-1195
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-4541
  • Fax: 304-776-4542
Mailing address:
  • Phone: 304-776-4541
  • Fax: 304-776-4542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3713
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: