Provider Demographics
NPI:1073887741
Name:SAMAN MADANI DMD & SHADI SHAREGHI DDS PC
Entity Type:Organization
Organization Name:SAMAN MADANI DMD & SHADI SHAREGHI DDS PC
Other - Org Name:SUNNY SMILES PEDIATRIC AND FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-865-5779
Mailing Address - Street 1:3930 PENDER DR
Mailing Address - Street 2:SUITE #250
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0985
Mailing Address - Country:US
Mailing Address - Phone:703-865-5779
Mailing Address - Fax:703-865-5543
Practice Address - Street 1:3930 PENDER DR
Practice Address - Street 2:SUITE #250
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:703-865-5779
Practice Address - Fax:703-865-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410760122300000X
VA04014126341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACX014Medicaid