Provider Demographics
NPI:1780885848
Name:POURMOGHADAM, LADAN (DDS)
Entity type:Individual
Prefix:
First Name:LADAN
Middle Name:
Last Name:POURMOGHADAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LADAN
Other - Middle Name:
Other - Last Name:POURMOGHADAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:6418 WINCHESTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-2005
Mailing Address - Country:US
Mailing Address - Phone:614-834-1834
Mailing Address - Fax:614-834-1875
Practice Address - Street 1:6418 WINCHESTER BLVD.
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-2005
Practice Address - Country:US
Practice Address - Phone:614-834-1834
Practice Address - Fax:614-834-1875
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH182711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice