Healthcare Provider Details

I. General information

NPI: 1073071197
Provider Name (Legal Business Name): SHADEN ALFAQIH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W ST NW
WASHINGTON DC
20059-5904
US

IV. Provider business mailing address

224 N FAYETTE ST
ALEXANDRIA VA
22314
US

V. Phone/Fax

Practice location:
  • Phone: 708-655-4984
  • Fax:
Mailing address:
  • Phone: 703-519-7275
  • Fax: 571-551-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401416205
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: