Healthcare Provider Details

I. General information

NPI: 1013405950
Provider Name (Legal Business Name): CHANTILLY MODERN DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14337 NEWBROOK DR. SUITE 200
CHANTILLY VA
20151
US

IV. Provider business mailing address

PO BOX 920050
DALLAS TX
75392-0050
US

V. Phone/Fax

Practice location:
  • Phone: 703-214-2113
  • Fax:
Mailing address:
  • Phone: 714-845-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEX R SHARIFIAN
Title or Position: OWNER/DDS
Credential: DDS
Phone: 703-214-2113