Provider Demographics
NPI:1659827871
Name:TESFAYE A HAILEMARIAM DDS PC
Entity Type:Organization
Organization Name:TESFAYE A HAILEMARIAM DDS PC
Other - Org Name:ADDISMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TESFAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILEMARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-256-7711
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22009-0141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5764 DOW AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-256-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA104989Medicaid