Healthcare Provider Details

I. General information

NPI: 1912849795
Provider Name (Legal Business Name): MIRPANAH & FAZEL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
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

9626 21ST BAY ST
NORFOLK VA
23518-1609
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB MIRPANAH
Title or Position: DENTIST
Credential: DDS, MS
Phone: 703-650-8265