Provider Demographics
NPI:1568733566
Name:KAMBIZ & KAMRAN TAVAKKOLI DMD PC
Entity Type:Organization
Organization Name:KAMBIZ & KAMRAN TAVAKKOLI DMD PC
Other - Org Name:ALEXANDRIA DENTAL PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GENET
Authorized Official - Middle Name:
Authorized Official - Last Name:OSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-360-1070
Mailing Address - Street 1:8403 RICHMOND HWY
Mailing Address - Street 2:SUITE I
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-2424
Mailing Address - Country:US
Mailing Address - Phone:703-360-1070
Mailing Address - Fax:
Practice Address - Street 1:8403 RICHMOND HWY
Practice Address - Street 2:SUITE I
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-2424
Practice Address - Country:US
Practice Address - Phone:703-360-1070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA200771553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty