Provider Demographics
NPI:1972199420
Name:HERNDON DENTAL CARE
Entity Type:Organization
Organization Name:HERNDON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AYESAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEMATI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-906-8367
Mailing Address - Street 1:12973 HIGHLAND CROSSING DR STE B
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-5890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12973 HIGHLAND CROSSING DR STE B
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-5890
Practice Address - Country:US
Practice Address - Phone:678-906-8367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty