=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801033329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BABAK GANJAVIAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2009
-----------------------------------------------------
Last Update Date | 05/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 TUSCANNY DR UNIT C
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-5958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-695-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6204 YORKSHIRE TER
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-526-9956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14228
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------