Healthcare Provider Details

I. General information

NPI: 1245985266
Provider Name (Legal Business Name): NOVA AFFORDABLE DENTAL IMPLANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8209 SUDLEY RD
MANASSAS VA
20109-3507
US

IV. Provider business mailing address

8209 SUDLEY RD
MANASSAS VA
20109-3507
US

V. Phone/Fax

Practice location:
  • Phone: 571-260-6222
  • Fax:
Mailing address:
  • Phone: 646-824-3829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. AHMED MATRI
Title or Position: OWNER
Credential:
Phone: 646-824-3829