=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194102228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED COSMETIC DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2015
-----------------------------------------------------
Last Update Date | 04/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1145 19TH ST NW STE 512
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-331-1644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1145 19TH ST NW STE 512
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-331-1644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER MEMBER
-----------------------------------------------------
Name | DR. AROUSHA JAHANGIRI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 202-331-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN1001167
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------