=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073641759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AESTHETIC DENTAL CENTER OF COLUMBIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10700 CHARTER DR STE 340
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-3695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-730-7779
-----------------------------------------------------
Fax | 410-730-9111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10700 CHARTER DR STE 340
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-3695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-730-7779
-----------------------------------------------------
Fax | 410-730-9111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAHVASH ZULFAGHARY
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 410-730-7779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 11926
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------