Provider Demographics
NPI:1083829444
Name:IZADI, MOHSEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:
Last Name:IZADI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MAPLE AVE E
Mailing Address - Street 2:SUITE 206
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-5741
Mailing Address - Country:US
Mailing Address - Phone:703-319-9880
Mailing Address - Fax:703-319-9885
Practice Address - Street 1:133 MAPLE AVE E
Practice Address - Street 2:SUITE 206
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-5741
Practice Address - Country:US
Practice Address - Phone:703-319-9880
Practice Address - Fax:703-319-9885
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA74841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice