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General NPI Number Information
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NPI Number | 1578283982
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Entity Type | Organization
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Legal Business Name | SEA DENTAL GROUP PLLC
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Dates
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Enumeration Date | 08/29/2022
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Last Update Date | 08/29/2022
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Provider Practice Location Address
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Address Line | 11934 W BROAD ST STE 120
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City | HENRICO
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State | VA
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Zip | 23233-1100
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Country | US
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Telephone | 818-800-2221
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Fax |
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Provider Business Mailing Address
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Address Line | 17113 BOLD VENTURE DR
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City | LEESBURG
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State | VA
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Zip | 20176-7169
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Country | US
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Telephone | 818-800-2221
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SALAR EBRAHIMI
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Credential | DDS
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Telephone | 818-800-2221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number |
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License Number State |
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