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General NPI Number Information
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NPI Number | 1932467180
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Entity Type | Organization
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Legal Business Name | CRYSTAL CITY DENTAL ARTS CENTER
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Dates
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Enumeration Date | 04/25/2012
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Last Update Date | 04/25/2012
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Provider Practice Location Address
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Address Line | 1615-E CRYSTAL SQUARE ARCADE
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City | ARLINGTON
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State | VA
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Zip | 22202
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Country | US
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Telephone | 202-599-9100
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Fax |
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Provider Business Mailing Address
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Address Line | 8304-C OLD COURTHOUSE RD.
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City | VIENNA
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State | VA
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Zip | 22182
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Country | US
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Telephone | 703-356-1200
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Fax | 703-356-6742
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON FAVAGEHI
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Credential | DDS
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Telephone | 703-356-1200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401007352
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License Number State | VA
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