=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336642388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERDAD DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2018
-----------------------------------------------------
Last Update Date | 03/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7522 OLD LINTON HALL RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-654-0359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 PORT ST APT 1626
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22314-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-654-0359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER CEO
-----------------------------------------------------
Name | HISHAM ESSAM A MERDAD
-----------------------------------------------------
Credential | BDS, DSCD
-----------------------------------------------------
Telephone | 857-654-0359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401414352
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------