=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164234910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELGHANNAM DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2025
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4421 DALE BLVD STE 202
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-499-0438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4421 DALE BLVD STE 202
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MOHAMED M ELGHANNAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-499-0438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------