Provider Demographics
NPI:1922198415
Name:MIRSAEIDE-FARAHANI, SEYED ALI (DDS)
Entity Type:Individual
Prefix:DR
First Name:SEYED
Middle Name:ALI
Last Name:MIRSAEIDE-FARAHANI
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 1:1775 MAIN ST. STE103
Mailing Address - Street 2:P.O.BOX 129
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026
Mailing Address - Country:US
Mailing Address - Phone:703-445-9022
Mailing Address - Fax:703-445-9043
Practice Address - Street 1:1775 MAIN ST. STE103
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026
Practice Address - Country:US
Practice Address - Phone:703-445-9022
Practice Address - Fax:703-445-9043
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014105021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice