Provider Demographics
NPI:1740590447
Name:TAVASSOLI, AMIR H (DDS)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:H
Last Name:TAVASSOLI
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 1:3017 MONTFORT LOOP
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5237
Mailing Address - Country:US
Mailing Address - Phone:703-371-8180
Mailing Address - Fax:
Practice Address - Street 1:9732 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4962
Practice Address - Country:US
Practice Address - Phone:804-320-3683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2013-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014130161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice