Healthcare Provider Details

I. General information

NPI: 1760065148
Provider Name (Legal Business Name): HUBIIN M HAILU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11654 PLAZA AMERICA DR # 163
RESTON VA
20190-4700
US

IV. Provider business mailing address

915 SILVER SPRING AVE APT 702
SILVER SPRING MD
20910-5125
US

V. Phone/Fax

Practice location:
  • Phone: 818-822-2278
  • Fax: 818-822-2278
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number19095
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: