Healthcare Provider Details

I. General information

NPI: 1780922187
Provider Name (Legal Business Name): AZITA ABBASI-HAFSHEJANI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2013
Last Update Date: 11/23/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46165 WESTLAKE DR STE 300
STERLING VA
20165-5872
US

IV. Provider business mailing address

46165 WESTLAKE DR STE 300
STERLING VA
20165-5872
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-9373
  • Fax: 847-496-7603
Mailing address:
  • Phone: 703-444-9373
  • Fax: 847-496-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.029300
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401413845
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: