Healthcare Provider Details

I. General information

NPI: 1558639906
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605D PINECREST OFFICE PARK DR
ALEXANDRIA VA
22312-1442
US

IV. Provider business mailing address

4605D PINECREST OFFICE PARK DR
ALEXANDRIA VA
22312-1442
US

V. Phone/Fax

Practice location:
  • Phone: 703-352-4121
  • Fax:
Mailing address:
  • Phone: 703-352-4121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401008254
License Number StateVA

VIII. Authorized Official

Name: DR. FARANAK GHALEHBAGHI
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 703-352-4121