Provider Demographics
NPI:1790067908
Name:QAMRUDDIN, NISAR H (DMD)
Entity Type:Individual
Prefix:
First Name:NISAR
Middle Name:H
Last Name:QAMRUDDIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 WALHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2622
Mailing Address - Country:US
Mailing Address - Phone:703-869-4213
Mailing Address - Fax:703-971-2335
Practice Address - Street 1:2904 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2522
Practice Address - Country:US
Practice Address - Phone:202-562-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN51241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice