Healthcare Provider Details

I. General information

NPI: 1093277808
Provider Name (Legal Business Name): REBAZ WAISE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 E WEST HWY
SILVER SPRING MD
20910-3242
US

IV. Provider business mailing address

7934 WENTWORTH PL
SPRINGFIELD VA
22152-3440
US

V. Phone/Fax

Practice location:
  • Phone: 301-761-4489
  • Fax:
Mailing address:
  • Phone: 703-965-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000487
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number18178
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401416705
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: