Healthcare Provider Details

I. General information

NPI: 1275450702
Provider Name (Legal Business Name): RAZIEH KHODABAKHSH DDS, MDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7970 MAITLAND ST APT 109
MC LEAN VA
22102-5158
US

IV. Provider business mailing address

7970 MAITLAND ST APT 109
MC LEAN VA
22102-5158
US

V. Phone/Fax

Practice location:
  • Phone: 914-772-6928
  • Fax:
Mailing address:
  • Phone: 914-772-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420152
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number0401420152
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: