Healthcare Provider Details

I. General information

NPI: 1801275995
Provider Name (Legal Business Name): ASHKAN DAVARY DOWLATABADY MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 LEE HWY
FAIRFAX VA
22030-5014
US

IV. Provider business mailing address

7755 LEGERE CT
MC LEAN VA
22102-4790
US

V. Phone/Fax

Practice location:
  • Phone: 949-338-8291
  • Fax:
Mailing address:
  • Phone: 949-338-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401417276
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17298
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: