MEDICARE: SASAN AHMADIYAR, DDS,PLLC

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	1223G0001X	General Practice Dentistry
2	1223G0001X	General Practice Dentistry	0401008767	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396259586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SASAN AHMADIYAR, DDS,PLLC

Provider Business Mailing Address
First Line	:	10608 LEAVELLS RD
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-1256
Country	:	US
Telephone Number	:	540-710-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1911 BALLENGER AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-6819
Country	:	US
Telephone Number	:	703-299-1200
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SASAN AHMADIYAR
Credential	:	DDS
Telephone Number	:	703-299-1200

Provider Enumeration Date	:	11/27/2017
Last Update Date	:	11/27/2017

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