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General NPI Number Information
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NPI Number | 1760916993
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Entity Type | Individual
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Provider Name | MEHDI MUSTAFA HASAN
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Gender | Male
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Dates
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Enumeration Date | 04/13/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4090 LAFAYETTE CENTER DR STE F
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City | CHANTILLY
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State | VA
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Zip | 20151-1244
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Country | US
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Telephone | 410-706-7116
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Fax |
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Provider Business Mailing Address
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Address Line | 4327 RAVENSWORTH RD APT 812
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City | ANNANDALE
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State | VA
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Zip | 22003-5652
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Country | US
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Telephone | 410-905-2271
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 16467
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401415660
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License Number State | VA
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