Healthcare Provider Details

I. General information

NPI: 1215863725
Provider Name (Legal Business Name): SHADEN DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11150 FAIRFAX BLVD STE 400
FAIRFAX VA
22030-5066
US

IV. Provider business mailing address

3794 RAINIER DR
FAIRFAX VA
22033-2990
US

V. Phone/Fax

Practice location:
  • Phone: 703-679-8042
  • Fax:
Mailing address:
  • Phone: 703-679-8042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHADEN ALFAQIH
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 703-679-8042