Healthcare Provider Details

I. General information

NPI: 1669468500
Provider Name (Legal Business Name): KIUMARS ELYASI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

8450 DORSEY RUN RD
JESSUP MD
20794-9486
US

IV. Provider business mailing address

2023 GEORGE WASHINGTON RD
VIENNA VA
22182-3711
US

V. Phone/Fax

Practice location:
  • Phone: 410-724-3153
  • Fax:
Mailing address:
  • Phone: 703-734-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10612
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: