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General NPI Number Information
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NPI Number | 1720277932
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Entity Type | Organization
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Legal Business Name | SKIN AND LASER SURGERY CENTER
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Dates
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Enumeration Date | 10/24/2007
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Last Update Date | 09/24/2008
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Provider Practice Location Address
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Address Line | 8130 BOONE BLVD SUITE 340
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City | VIENNA
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State | VA
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Zip | 22182-2666
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Country | US
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Telephone | 703-492-4140
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Fax | 703-490-6443
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Provider Business Mailing Address
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Address Line | PO BOX 2010
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City | MERRIFIELD
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State | VA
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Zip | 22116-2010
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Country | US
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Telephone | 703-492-4140
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Fax | 703-492-5409
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AMIR BAJOGHLI
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Credential | MD
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Telephone | 703-492-4140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 0101053252
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License Number State | VA
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