MEDICARE: MOJDEH KHALILI, DDS, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401007490	VA

General Provider Information

NPI Number	:	1497964183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOJDEH KHALILI, DDS, LTD.

Provider Business Mailing Address
First Line	:	3317 DUKE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4522
Country	:	US
Telephone Number	:	703-212-0400
Fax Number	:	703-212-0423

Provider Business Practice Location Address
First Line	:	3317 DUKE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4522
Country	:	US
Telephone Number	:	703-212-0400
Fax Number	:	703-212-0423

Authorized Official
Title or Position	:	S-CORP PRESIDENT
Name	:	DR. MOJDEH KHALILI
Credential	:	DDS
Telephone Number	:	703-212-0400

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/22/2020

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