Provider Demographics
NPI:1174011191
Name:FAIRFAX MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:FAIRFAX MODERN DENTISTRY, PC
Other - Org Name:FAIRFAX MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DMD
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHRESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-520-6376
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8280
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:11050 LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5014
Practice Address - Country:US
Practice Address - Phone:703-520-6376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty