Healthcare Provider Details

I. General information

NPI: 1952909731
Provider Name (Legal Business Name): KIMIA KHOSHROO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 KEMPSVILLE RD STE 101
VIRGINIA BEACH VA
23464-7302
US

IV. Provider business mailing address

1444 KEMPSVILLE RD STE 101
VIRGINIA BEACH VA
23464-7302
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-8611
  • Fax:
Mailing address:
  • Phone: 757-497-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401417209
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401417209
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: