Provider Demographics
NPI:1750071668
Name:NABIZADEH, ARDALAN
Entity type:Individual
Prefix:
First Name:ARDALAN
Middle Name:
Last Name:NABIZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 EQUESTRIAN TRL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9765
Mailing Address - Country:US
Mailing Address - Phone:781-888-0603
Mailing Address - Fax:
Practice Address - Street 1:1016 MAIN ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24504-1712
Practice Address - Country:US
Practice Address - Phone:434-847-5866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014184671223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program