Provider Demographics
NPI:1962916783
Name:DERAKHSHAN, MITRA (DDS MS)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:DERAKHSHAN
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5082 DORSEY HALL DR STE 202
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7754
Practice Address - Country:US
Practice Address - Phone:202-445-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10006771223X0400X
CA490901223X0400X
MD127311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics