Provider Demographics
NPI:1962587063
Name:MIRMIRAN, FARNOUSH (DDS)
Entity type:Individual
Prefix:
First Name:FARNOUSH
Middle Name:
Last Name:MIRMIRAN
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 1:10320 WESTLAKE DR
Mailing Address - Street 2:APT 207
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817
Mailing Address - Country:US
Mailing Address - Phone:301-469-0406
Mailing Address - Fax:
Practice Address - Street 1:12105 DARNESTOWN RD
Practice Address - Street 2:SUITE 18
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878
Practice Address - Country:US
Practice Address - Phone:301-869-6600
Practice Address - Fax:301-869-9765
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD115881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice