Provider Demographics
NPI:1013523380
Name:TELLAWI, NOUR HUSSAM
Entity Type:Individual
Prefix:
First Name:NOUR
Middle Name:HUSSAM
Last Name:TELLAWI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 STEVENSON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-3526
Mailing Address - Country:US
Mailing Address - Phone:571-297-2855
Mailing Address - Fax:
Practice Address - Street 1:6000 STEVENSON AVE STE 103
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-3526
Practice Address - Country:US
Practice Address - Phone:571-297-2855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist