Healthcare Provider Details

I. General information

NPI: 1982340444
Provider Name (Legal Business Name): AHMED HABEEBALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 CANFORD LOOP
MIDLOTHIAN VA
23112-4575
US

IV. Provider business mailing address

3237 CANFORD LOOP
MIDLOTHIAN VA
23112-4575
US

V. Phone/Fax

Practice location:
  • Phone: 585-612-1199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026946
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418085
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: