=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952872285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE LOUDOUN DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44790 MAYNARD SQ STE 180
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-729-7900
-----------------------------------------------------
Fax | 703-729-3085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44790 MAYNARD SQ STE 180
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-729-7900
-----------------------------------------------------
Fax | 703-729-3085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DARIUOSH ASHOURIPOUR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-625-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------