Provider Demographics
NPI:1073715314
Name:AZMOUDEH, ROXANNE
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:
Last Name:AZMOUDEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:
Other - Last Name:HARIRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:44355 PREMIER PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5050
Mailing Address - Country:US
Mailing Address - Phone:703-858-9146
Mailing Address - Fax:703-858-9147
Practice Address - Street 1:44355 PREMIER PLZ STE 100
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5050
Practice Address - Country:US
Practice Address - Phone:703-858-9146
Practice Address - Fax:703-858-9147
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109791223G0001X
MD133951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice