Provider Demographics
NPI:1689100315
Name:HEMATI, AYESAN
Entity Type:Individual
Prefix:
First Name:AYESAN
Middle Name:
Last Name:HEMATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3339
Mailing Address - Country:US
Mailing Address - Phone:703-533-7285
Mailing Address - Fax:
Practice Address - Street 1:105 N VIRGINIA AVE STE 103
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3323
Practice Address - Country:US
Practice Address - Phone:703-533-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014171441223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics