Provider Demographics
NPI:1851876478
Name:MOUSAVI, SINA
Entity Type:Individual
Prefix:
First Name:SINA
Middle Name:
Last Name:MOUSAVI
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 1:13625 OFFICE PL STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4270
Mailing Address - Country:US
Mailing Address - Phone:571-470-7239
Mailing Address - Fax:
Practice Address - Street 1:1175 MOUNT HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9060
Practice Address - Country:US
Practice Address - Phone:503-982-2000
Practice Address - Fax:503-982-0660
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11398122300000X
WADE60882838122300000X
VA0401418368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist