Healthcare Provider Details

I. General information

NPI: 1932971850
Provider Name (Legal Business Name): FAIRFAX PERIODONTAL AND IMPLANT CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8622 ROUTE 29 STE D
FAIRFAX VA
22031-2148
US

IV. Provider business mailing address

8622 ROUTE 29 STE D
FAIRFAX VA
22031-2148
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-2974
  • Fax:
Mailing address:
  • Phone: 703-491-2974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: AHMAD HAWASLI
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 703-491-2974