MEDICARE: SEYEDEH ZAHRA HASSANTASH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401415845	VA
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	102304	CA

General Provider Information

NPI Number	:	1346741352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEYEDEH ZAHRA HASSANTASH

Provider Business Mailing Address
First Line	:	1800 JONATHAN WAY APT 723
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20190-3693
Country	:	US
Telephone Number	:	626-589-6025
Fax Number	:

Provider Business Practice Location Address
First Line	:	11415 LEGACY TER
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-3579
Country	:	US
Telephone Number	:	626-589-6025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2018
Last Update Date	:	10/01/2019

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