Provider Demographics
NPI:1275830473
Name:ASHBURN ORTHODONTICS
Entity Type:Organization
Organization Name:ASHBURN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:SAHIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KORTAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSC, MS
Authorized Official - Phone:347-761-7199
Mailing Address - Street 1:44345 PREMIER PLZ
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5053
Mailing Address - Country:US
Mailing Address - Phone:347-761-7199
Mailing Address - Fax:
Practice Address - Street 1:44345 PREMIER PLZ
Practice Address - Street 2:SUITE 140
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5053
Practice Address - Country:US
Practice Address - Phone:347-761-7199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412813261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental