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General NPI Number Information
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NPI Number | 1164440608
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Entity Type | Individual
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Provider Name | MOHAMMAD - IZADIDEHKORDI D.D.S
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Gender | Male
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 11/05/2021
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Provider Practice Location Address
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Address Line | 12209 TULLAMORE RD
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City | TIMONIUM
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State | MD
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Zip | 21093-7816
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Country | US
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Telephone | 410-560-0360
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Fax | 410-560-0364
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Provider Business Mailing Address
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Address Line | 11400 LAKE POTOMAC DR
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City | POTOMAC
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State | MD
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Zip | 20854-1216
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Country | US
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Telephone | 301-983-0818
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Fax | 301-983-0650
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 11080
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0401008006
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License Number State | VA
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