Healthcare Provider Details

I. General information

NPI: 1174011191
Provider Name (Legal Business Name): FAIRFAX MODERN DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 LEE HWY
FAIRFAX VA
22030-5014
US

IV. Provider business mailing address

PO BOX 920050
DALLAS TX
75392-0050
US

V. Phone/Fax

Practice location:
  • Phone: 703-520-6376
  • Fax:
Mailing address:
  • Phone: 714-845-8280
  • Fax: 303-952-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ALI SHAHRESTANI
Title or Position: OWNER/DMD
Credential: DMD
Phone: 703-520-6376