Healthcare Provider Details

I. General information

NPI: 1053993295
Provider Name (Legal Business Name): FARNAZ YOUNESSIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 FAIR RIDGE DR STE 215
FAIRFAX VA
22033-2945
US

IV. Provider business mailing address

10610 CANFIELD ST
FAIRFAX VA
22030-8155
US

V. Phone/Fax

Practice location:
  • Phone: 571-559-1343
  • Fax:
Mailing address:
  • Phone: 949-527-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401416814
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: