Provider Demographics
NPI:1235128950
Name:MORTAZIE, MANSOUR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANSOUR
Middle Name:
Last Name:MORTAZIE
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 1:313 PARK AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3327
Mailing Address - Country:US
Mailing Address - Phone:703-237-0662
Mailing Address - Fax:703-883-1114
Practice Address - Street 1:313 PARK AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3327
Practice Address - Country:US
Practice Address - Phone:703-237-0662
Practice Address - Fax:703-883-1114
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-15
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005721122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007819315Medicaid