Provider Demographics
NPI:1760036891
Name:KHAMOOSHI, KASRA
Entity Type:Individual
Prefix:DR
First Name:KASRA
Middle Name:
Last Name:KHAMOOSHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 FOXSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2131
Mailing Address - Country:US
Mailing Address - Phone:571-296-6419
Mailing Address - Fax:
Practice Address - Street 1:5205 LEESBURG PIKE STE 1406
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-3894
Practice Address - Country:US
Practice Address - Phone:703-998-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist