Healthcare Provider Details

I. General information

NPI: 1235060864
Provider Name (Legal Business Name): PROVIDENCE DENTAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 JAVIER RD STE 101
FAIRFAX VA
22031-4622
US

IV. Provider business mailing address

3028 JAVIER RD STE 101
FAIRFAX VA
22031-4622
US

V. Phone/Fax

Practice location:
  • Phone: 301-222-7896
  • Fax: 301-222-7896
Mailing address:
  • Phone: 301-222-7896
  • Fax: 301-222-7896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ISSA I ABOU AYYASH
Title or Position: DENTIST
Credential:
Phone: 301-222-7896