Healthcare Provider Details

I. General information

NPI: 1740008499
Provider Name (Legal Business Name): OPANN DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 EVERGREEN LN
ANNANDALE VA
22003-3209
US

IV. Provider business mailing address

4220 EVERGREEN LN
ANNANDALE VA
22003-3209
US

V. Phone/Fax

Practice location:
  • Phone: 646-648-2528
  • Fax:
Mailing address:
  • Phone: 646-648-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. AMIN NEISHABOORY
Title or Position: OWNER/ORTHODONTIST
Credential:
Phone: 646-648-2528