Provider Demographics
NPI:1639603459
Name:KOUROS HEDAYATI, DDS, PLC
Entity Type:Organization
Organization Name:KOUROS HEDAYATI, DDS, PLC
Other - Org Name:BREEZE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUROS
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDAYATI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-225-1038
Mailing Address - Street 1:3545 CHAIN BRIDGE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2708
Mailing Address - Country:US
Mailing Address - Phone:703-273-5545
Mailing Address - Fax:703-591-8702
Practice Address - Street 1:3545 CHAIN BRIDGE RD STE 5
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2708
Practice Address - Country:US
Practice Address - Phone:703-273-5545
Practice Address - Fax:703-591-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014122011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty