Provider Demographics
NPI:1396845558
Name:ALI, WISSAM FAWZI (DMD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:FAWZI
Last Name:ALI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7409 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-3812
Mailing Address - Country:US
Mailing Address - Phone:703-672-6919
Mailing Address - Fax:703-451-1863
Practice Address - Street 1:7409 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-3812
Practice Address - Country:US
Practice Address - Phone:703-672-6919
Practice Address - Fax:703-451-1863
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410503122300000X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist