Healthcare Provider Details

I. General information

NPI: 1487054128
Provider Name (Legal Business Name): ASHBURNFARM DENTAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2014
Last Update Date: 08/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43330 JUNCTION PLAZA SUITE 122
ASHBURN VA
20147
US

IV. Provider business mailing address

43330 JUNCTION PLZ STE 122
ASHBURN VA
20147-3407
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-7900
  • Fax:
Mailing address:
  • Phone: 703-729-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License Number7312
License Number StateVA

VIII. Authorized Official

Name: DR. DAN D ASHOURIPOUR
Title or Position: PRESIDENT
Credential: DDS
Phone: 703-625-6800