Provider Demographics
NPI:1689009961
Name:SANAE BOUALLALI BERRADA
Entity Type:Organization
Organization Name:SANAE BOUALLALI BERRADA
Other - Org Name:TYSONS DENTAL ESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRADA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-821-8111
Mailing Address - Street 1:7641 LEESBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2520
Mailing Address - Country:US
Mailing Address - Phone:703-821-8111
Mailing Address - Fax:703-821-1512
Practice Address - Street 1:7641 LEESBURG PIKE
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2520
Practice Address - Country:US
Practice Address - Phone:703-821-8111
Practice Address - Fax:703-821-1512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty