Healthcare Provider Details

I. General information

NPI: 1285813857
Provider Name (Legal Business Name): ROUBEN A YEDIGARIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8371B GREENSBORO DR
MC LEAN VA
22102-3529
US

IV. Provider business mailing address

8371B GREENSBORO DR
MC LEAN VA
22102-3529
US

V. Phone/Fax

Practice location:
  • Phone: 703-821-0882
  • Fax: 703-821-2187
Mailing address:
  • Phone: 703-821-0882
  • Fax: 710-821-2187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number401005564
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0401005564
License Number StateVA

VIII. Authorized Official

Name: DR. ROUBEN A YEDIGARIAN
Title or Position: D.D.S.
Credential: D.D.S.
Phone: 703-821-0882