MEDICARE: DR. KHASHAYAR KORDBACHEH CHANGI DMD MS

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	1223P0300X	Periodontics	0401416202	VA

General Provider Information

NPI Number	:	1750860516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHASHAYAR KORDBACHEH CHANGI DMD MS

Provider Business Mailing Address
First Line	:	2500 WISCONSIN AVE NW APT 559
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-4513
Country	:	US
Telephone Number	:	949-424-4383
Fax Number	:

Provider Business Practice Location Address
First Line	:	3543 W BRADDOCK RD STE E2
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-1903
Country	:	US
Telephone Number	:	703-820-0809
Fax Number	:

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

Provider Enumeration Date	:	08/11/2018
Last Update Date	:	08/11/2018

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