Provider Demographics
NPI:1487729786
Name:GANJAVIAN, SYAMACK (DDS)
Entity type:Individual
Prefix:DR
First Name:SYAMACK
Middle Name:
Last Name:GANJAVIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-5014
Mailing Address - Country:US
Mailing Address - Phone:302-230-0000
Mailing Address - Fax:302-295-3607
Practice Address - Street 1:129 S WEST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-5014
Practice Address - Country:US
Practice Address - Phone:302-230-0000
Practice Address - Fax:302-295-3607
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG100011841223G0001X
MD135051223G0001X
PADS0369821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000033854Medicaid