Provider Demographics
NPI:1811933849
Name:GHODRAT, HUSHANG (DDS)
Entity type:Individual
Prefix:DR
First Name:HUSHANG
Middle Name:
Last Name:GHODRAT
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 1:560 DABNEY DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 DABNEY DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5919
Practice Address - Country:US
Practice Address - Phone:252-492-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011G5OtherBCBS PROVIDER #
NC6984OtherDELTA DENTAL PROVIDER #
NC8990121Medicaid