=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235307257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELIKA SHATERGHOLI D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2008
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3327 SUPERIOR LANE SUITE 101
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-678-3658
-----------------------------------------------------
Fax | 310-464-2125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3327 SUPERIOR LANE SUITE 101
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-678-3658
-----------------------------------------------------
Fax | 310-464-2125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 14213
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------