=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639724461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL SMILE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 08/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2611 JEFFERSON DAVIS HWY STE 200
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22202-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-295-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8304 OLD COURTHOUSE RD STE C
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-356-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON FAVAGEHI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-356-1200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------