Provider Demographics
NPI:1750860516
Name:KORDBACHEH CHANGI, KHASHAYAR (DMD MS)
Entity Type:Individual
Prefix:DR
First Name:KHASHAYAR
Middle Name:
Last Name:KORDBACHEH CHANGI
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 WISCONSIN AVE NW APT 559
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-4513
Mailing Address - Country:US
Mailing Address - Phone:949-424-4383
Mailing Address - Fax:
Practice Address - Street 1:3543 W BRADDOCK RD STE E2
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1903
Practice Address - Country:US
Practice Address - Phone:703-820-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014162021223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty