Provider Demographics
NPI:1942742861
Name:DR. MOJDEH VESSALI FAMILY DENTISTRY
Entity Type:Organization
Organization Name:DR. MOJDEH VESSALI FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOJDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-736-0900
Mailing Address - Street 1:505 HUNTMAR PARK DR
Mailing Address - Street 2:#150
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5103
Mailing Address - Country:US
Mailing Address - Phone:703-736-0900
Mailing Address - Fax:703-736-0666
Practice Address - Street 1:505 HUNTMAR PARK DRIVE
Practice Address - Street 2:#150
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:703-736-0900
Practice Address - Fax:703-736-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty