Provider Demographics
NPI:1184732216
Name:IZADI, KEYOUMARS (MD, DDS)
Entity type:Individual
Prefix:DR
First Name:KEYOUMARS
Middle Name:
Last Name:IZADI
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CHATHAM SQUARE OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2561
Mailing Address - Country:US
Mailing Address - Phone:540-371-4131
Mailing Address - Fax:540-371-5621
Practice Address - Street 1:409 CHATHAM SQUARE OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-2561
Practice Address - Country:US
Practice Address - Phone:540-371-4131
Practice Address - Fax:540-371-5621
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243951208200000X
VA0401412094122300000X
VA04380002431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery