Provider Demographics
NPI:1215670161
Name:BAHRAM, VANA GHAZY (DDS)
Entity type:Individual
Prefix:
First Name:VANA
Middle Name:GHAZY
Last Name:BAHRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 RUISSEAU ST UNIT 1407
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3668
Mailing Address - Country:US
Mailing Address - Phone:214-864-7678
Mailing Address - Fax:
Practice Address - Street 1:40 PITTS SCHOOL RD SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-3931
Practice Address - Country:US
Practice Address - Phone:704-461-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX38874122300000X
NC12987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program