Healthcare Provider Details

I. General information

NPI: 1023213758
Provider Name (Legal Business Name): REZA FARDSHISHEH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE STE 314
SPRINGFIELD VA
22150-2504
US

IV. Provider business mailing address

11359 SUNSET HILLS RD
RESTON VA
20190-5275
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-0002
  • Fax: 703-569-8758
Mailing address:
  • Phone: 703-437-6666
  • Fax: 703-435-8281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401411770
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: