Healthcare Provider Details

I. General information

NPI: 1710198775
Provider Name (Legal Business Name): AHMED M ELGHOBASHI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE SUITE 214
SPRINGFIELD VA
22150
US

IV. Provider business mailing address

6120 BRANDON AVE SUITE 214
SPRINGFIELD VA
22150
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-1656
  • Fax: 703-451-3347
Mailing address:
  • Phone: 703-451-1656
  • Fax: 703-451-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401411676
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411676
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: