Provider Demographics
NPI:1053557447
Name:GHAVAM, MEHDI LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:LEE
Last Name:GHAVAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2058
Mailing Address - Country:US
Mailing Address - Phone:541-482-1744
Mailing Address - Fax:541-482-4128
Practice Address - Street 1:277 5TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2058
Practice Address - Country:US
Practice Address - Phone:541-482-1744
Practice Address - Fax:541-482-4128
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD84251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice