Provider Demographics
NPI:1851302012
Name:HAILEMARIAM, TESFAYE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TESFAYE
Middle Name:
Last Name:HAILEMARIAM
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:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22009-0141
Mailing Address - Country:US
Mailing Address - Phone:703-256-7711
Mailing Address - Fax:703-256-6226
Practice Address - Street 1:85 S BRAGG ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-2797
Practice Address - Country:US
Practice Address - Phone:703-256-7711
Practice Address - Fax:703-256-6226
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA104989Medicaid