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General NPI Number Information
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NPI Number | 1023213758
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Entity Type | Individual
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Provider Name | REZA FARDSHISHEH DMD
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Gender | Male
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6120 BRANDON AVE STE 314
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City | SPRINGFIELD
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State | VA
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Zip | 22150-2504
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Country | US
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Telephone | 703-569-0002
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Fax | 703-569-8758
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Provider Business Mailing Address
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Address Line | 11359 SUNSET HILLS RD
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City | RESTON
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State | VA
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Zip | 20190-5275
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Country | US
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Telephone | 703-437-6666
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Fax | 703-435-8281
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 0401411770
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License Number State | VA
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