=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720876758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMINA YARAEI SHAHMIRZADI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2025
-----------------------------------------------------
Last Update Date | 06/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6428 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20012-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-371-2963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 WESTEDGE ST UNIT 527
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29403-6919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-371-2963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN2001553
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------