Provider Demographics
NPI:1669468500
Name:ELYASI, KIUMARS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIUMARS
Middle Name:
Last Name:ELYASI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 GEORGE WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3711
Mailing Address - Country:US
Mailing Address - Phone:703-734-2023
Mailing Address - Fax:
Practice Address - Street 1:8450 DORSEY RUN RD
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:MD
Practice Address - Zip Code:20794-9486
Practice Address - Country:US
Practice Address - Phone:410-724-3153
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MD106121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice