Provider Demographics
NPI:1598822371
Name:ALAYSSAMI, MAZIN
Entity Type:Individual
Prefix:
First Name:MAZIN
Middle Name:
Last Name:ALAYSSAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13873 PARK CENTER RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3223
Mailing Address - Country:US
Mailing Address - Phone:703-478-0115
Mailing Address - Fax:
Practice Address - Street 1:13873 PARK CENTER RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3223
Practice Address - Country:US
Practice Address - Phone:703-478-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA84161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice