Healthcare Provider Details

I. General information

NPI: 1245119932
Provider Name (Legal Business Name): TINA ABOLGHASEMI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14337 NEWBROOK DR STE 200
CHANTILLY VA
20151-4259
US

IV. Provider business mailing address

700 N RANDOLPH ST APT 1112
ARLINGTON VA
22203-2187
US

V. Phone/Fax

Practice location:
  • Phone: 703-214-2113
  • Fax:
Mailing address:
  • Phone: 202-669-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419593
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: