Provider Demographics
NPI:1255482444
Name:TARI, KIANOUSH M (DMD, MS, PC)
Entity Type:Individual
Prefix:DR
First Name:KIANOUSH
Middle Name:M
Last Name:TARI
Suffix:
Gender:F
Credentials:DMD, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17333 PICKWICK DR STE A
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-6161
Mailing Address - Country:US
Mailing Address - Phone:540-338-0004
Mailing Address - Fax:540-338-0757
Practice Address - Street 1:17333 PICKWICK DR STE A
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-6161
Practice Address - Country:US
Practice Address - Phone:540-338-0004
Practice Address - Fax:540-338-0757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010088721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics