Provider Demographics
NPI:1760156558
Name:KHOSRAVI, PARDIS
Entity Type:Individual
Prefix:
First Name:PARDIS
Middle Name:
Last Name:KHOSRAVI
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 1:1837 PEABODY DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-1035
Mailing Address - Country:US
Mailing Address - Phone:571-331-6563
Mailing Address - Fax:
Practice Address - Street 1:3800 FAIRFAX DR STE 6
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1703
Practice Address - Country:US
Practice Address - Phone:703-249-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014175771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice