Healthcare Provider Details

I. General information

NPI: 1295055762
Provider Name (Legal Business Name): FARZANEH ROSTAMI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 19TH ST NW STE 777
WASHINGTON DC
20036-3744
US

IV. Provider business mailing address

4701 RANDOLPH RD STE G10
ROCKVILLE MD
20852-2259
US

V. Phone/Fax

Practice location:
  • Phone: 22-296-6600
  • Fax:
Mailing address:
  • Phone: 301-468-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401413397
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN1001418
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: