Provider Demographics
NPI:1285990556
Name:GHALEHGOL, AMIR (DMD)
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:GHALEHGOL
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 1:5252 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1969
Mailing Address - Country:US
Mailing Address - Phone:404-252-5252
Mailing Address - Fax:
Practice Address - Street 1:5252 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1969
Practice Address - Country:US
Practice Address - Phone:404-252-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0144721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN014472OtherSTATE LICENSE