Provider Demographics
NPI:1578283982
Name:SEA DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:SEA DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALAR
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-800-2221
Mailing Address - Street 1:17113 BOLD VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-7169
Mailing Address - Country:US
Mailing Address - Phone:818-800-2221
Mailing Address - Fax:
Practice Address - Street 1:11934 W BROAD ST STE 120
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1100
Practice Address - Country:US
Practice Address - Phone:818-800-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty