Provider Demographics
NPI:1093313181
Name:SEIFOLAHI BAZARJANI, KOUROSH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:SEIFOLAHI BAZARJANI
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 1:1801 ROBERT FULTON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4347
Mailing Address - Country:US
Mailing Address - Phone:703-495-3333
Mailing Address - Fax:
Practice Address - Street 1:1801 ROBERT FULTON DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-4347
Practice Address - Country:US
Practice Address - Phone:703-495-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014172191223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice