Healthcare Provider Details

I. General information

NPI: 1811028681
Provider Name (Legal Business Name): MANDANA GHASEMZADEH ZOLGHADR D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6082 FRANCONIA RD SUITE B
ALEXANDRIA VA
22310-4428
US

IV. Provider business mailing address

9710 MIDDLETON RIDGE RD
VIENNA VA
22182-1497
US

V. Phone/Fax

Practice location:
  • Phone: 703-719-0064
  • Fax: 703-719-9709
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401007854
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: