Provider Demographics
NPI:1295836799
Name:FATTAHI, TIRDAD
Entity Type:Individual
Prefix:
First Name:TIRDAD
Middle Name:
Last Name:FATTAHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 MACARTHUR BLVD NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1565
Mailing Address - Country:US
Mailing Address - Phone:202-338-7499
Mailing Address - Fax:202-338-8745
Practice Address - Street 1:4840 MACARTHUR BLVD., NW
Practice Address - Street 2:SUITE 101
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2550
Practice Address - Country:US
Practice Address - Phone:202-338-7499
Practice Address - Fax:202-338-8745
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC48101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC521-82-7235OtherTAX ID NUMBER