Healthcare Provider Details

I. General information

NPI: 1013653518
Provider Name (Legal Business Name): JACOB MIRPANAH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 FIRST COLONIAL RD STE 200
VIRGINIA BEACH VA
23454-3196
US

IV. Provider business mailing address

44040 BRUCETON MILLS CIR
ASHBURN VA
20147-4808
US

V. Phone/Fax

Practice location:
  • Phone: 757-412-2235
  • Fax:
Mailing address:
  • Phone: 703-650-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401417927
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: