Provider Demographics
NPI:1568021012
Name:ENDODONTICS OF GAITHERSBURG, LLC
Entity Type:Organization
Organization Name:ENDODONTICS OF GAITHERSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:EGHTESADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-527-0303
Mailing Address - Street 1:847 QUINCE ORCHARD BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1677
Mailing Address - Country:US
Mailing Address - Phone:301-527-0303
Mailing Address - Fax:301-527-0404
Practice Address - Street 1:847 QUINCE ORCHARD BLVD STE G
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1677
Practice Address - Country:US
Practice Address - Phone:301-527-0303
Practice Address - Fax:301-527-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty