Healthcare Provider Details

I. General information

NPI: 1942742861
Provider Name (Legal Business Name): DR. MOJDEH VESSALI FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 HUNTMAR PARK DRIVE #150
HERNDON VA
20170
US

IV. Provider business mailing address

505 HUNTMAR PARK DR #150
HERNDON VA
20170-5103
US

V. Phone/Fax

Practice location:
  • Phone: 703-736-0900
  • Fax: 703-736-0666
Mailing address:
  • Phone: 703-736-0900
  • Fax: 703-736-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. MOJDEH VESSALI
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 703-736-0900