Provider Demographics
NPI:1720109200
Name:ABU-GHANNAM, MEDHAT R (DDS)
Entity type:Individual
Prefix:DR
First Name:MEDHAT
Middle Name:R
Last Name:ABU-GHANNAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MEDHAT
Other - Middle Name:R
Other - Last Name:GHANNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2520 TERRA COTTA CIR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171
Mailing Address - Country:US
Mailing Address - Phone:703-956-6015
Mailing Address - Fax:
Practice Address - Street 1:9239 OLD KEENE MILL RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-4202
Practice Address - Country:US
Practice Address - Phone:703-455-7770
Practice Address - Fax:703-997-2530
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014108461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice