Provider Demographics
NPI:1417587312
Name:HERNDON MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:HERNDON MODERN DENTISTRY, PC
Other - Org Name:HERNDON MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHARIFIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-259-8477
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2537 JOHN MILTON DR.
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20171
Practice Address - Country:US
Practice Address - Phone:703-259-8477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-20
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty