Provider Demographics
NPI:1205307238
Name:IDEAL ENDODONTICS OF WOODBRIDGE PLLC
Entity type:Organization
Organization Name:IDEAL ENDODONTICS OF WOODBRIDGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JABBAR DARJANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-402-4038
Mailing Address - Street 1:3102 GOLANSKY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3102 GOLANSKY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4244
Practice Address - Country:US
Practice Address - Phone:571-991-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty