=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609357235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DENTAL ANESTHESIA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2018
-----------------------------------------------------
Last Update Date | 08/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10611 BRADDOCK RD
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22032-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-265-0805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2776 S ARLINGTON MILL DR # 121
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22206-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REZA IZADI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 202-265-0508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | FI5268405
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------