Provider Demographics
NPI:1184233256
Name:DIANAT, SEYED OMID
Entity type:Individual
Prefix:
First Name:SEYED OMID
Middle Name:
Last Name:DIANAT
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 1:13880 BRADDOCK RD STE 307
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2462
Mailing Address - Country:US
Mailing Address - Phone:703-815-3636
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 307
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2462
Practice Address - Country:US
Practice Address - Phone:703-815-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014170911223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty