Healthcare Provider Details

I. General information

NPI: 1629492871
Provider Name (Legal Business Name): SHERRY ANOUSHFAR D D S P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 MAPLE AVE E 206
VIENNA VA
22180-5741
US

IV. Provider business mailing address

133 MAPLE AVE E SUITE 206
VIENNA VA
22180-5741
US

V. Phone/Fax

Practice location:
  • Phone: 703-319-9880
  • Fax: 703-319-9985
Mailing address:
  • Phone: 703-319-9880
  • Fax: 703-319-9985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7484
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHSEN IZADI
Title or Position: DOCTOR
Credential: D.D.S.
Phone: 703-319-9880