Healthcare Provider Details

I. General information

NPI: 1376627844
Provider Name (Legal Business Name): ALI YOUSEF GHATRI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6564 LOISDALE CT STE 110
SPRINGFIELD VA
22150-1822
US

IV. Provider business mailing address

6564 LOISDALE CT STE 110
SPRINGFIELD VA
22150-1822
US

V. Phone/Fax

Practice location:
  • Phone: 703-719-5828
  • Fax:
Mailing address:
  • Phone: 703-719-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401-007950
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: