Healthcare Provider Details

I. General information

NPI: 1720624307
Provider Name (Legal Business Name): DEENA HADITHI DMD, PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 OLD KEENE MILL RD STE 3
SPRINGFIELD VA
22150-3442
US

IV. Provider business mailing address

7210 OLD KEENE MILL RD STE 3
SPRINGFIELD VA
22150-3442
US

V. Phone/Fax

Practice location:
  • Phone: 703-644-7300
  • Fax: 703-866-4319
Mailing address:
  • Phone: 703-644-7300
  • Fax: 703-866-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DEENA HADITHI
Title or Position: PRESIDENT
Credential: DMD
Phone: 703-644-7300