Provider Demographics
NPI:1497163638
Name:MITRA HOOSHANGI DDS, LLC
Entity Type:Organization
Organization Name:MITRA HOOSHANGI DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOSHANGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-893-7900
Mailing Address - Street 1:2112 GALLOWS RD # D
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3963
Mailing Address - Country:US
Mailing Address - Phone:703-893-7900
Mailing Address - Fax:
Practice Address - Street 1:2112 GALLOWS RD # D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3963
Practice Address - Country:US
Practice Address - Phone:703-893-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty