Healthcare Provider Details

I. General information

NPI: 1114810348
Provider Name (Legal Business Name): ABDELRAHMAN ABOULATTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 OLD IVY RD STE 3
CHARLOTTESVILLE VA
22903-4820
US

IV. Provider business mailing address

3207 HORIZON RD
CHARLOTTESVILLE VA
22902-6639
US

V. Phone/Fax

Practice location:
  • Phone: 434-293-8944
  • Fax:
Mailing address:
  • Phone: 757-869-0667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: