Provider Demographics
NPI:1639724461
Name:CRYSTAL SMILE, PLLC
Entity Type:Organization
Organization Name:CRYSTAL SMILE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVAGEHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-356-1200
Mailing Address - Street 1:8304 OLD COURTHOUSE RD STE C
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3881
Mailing Address - Country:US
Mailing Address - Phone:703-356-1200
Mailing Address - Fax:
Practice Address - Street 1:2611 JEFFERSON DAVIS HWY STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-4043
Practice Address - Country:US
Practice Address - Phone:571-295-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401007352OtherLICENSE