MEDICARE: MRS. NASTARAN EJTEMAI DDS

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	0401007839	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0401009839	OTHER	VA	COMMONWEALTH OF VA

General Provider Information

NPI Number	:	1780724443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NASTARAN EJTEMAI DDS

Provider Business Mailing Address
First Line	:	9671 A MAIN STREET
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031
Country	:	US
Telephone Number	:	703-323-0700
Fax Number	:	703-323-8343

Provider Business Practice Location Address
First Line	:	9671 A MAIN STREET
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031
Country	:	US
Telephone Number	:	703-323-0700
Fax Number	:	703-323-8343

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/08/2007

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