Provider Demographics
NPI:1265884423
Name:RESTON FAMILY DENTIST GROUP PLLC
Entity type:Organization
Organization Name:RESTON FAMILY DENTIST GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MIAMEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-423-7945
Mailing Address - Street 1:12025 TOWN SQUARE ST
Mailing Address - Street 2:UNIT 424
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-6026
Mailing Address - Country:US
Mailing Address - Phone:571-423-7945
Mailing Address - Fax:571-313-0576
Practice Address - Street 1:1801 ROBERT FULTON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5461
Practice Address - Country:US
Practice Address - Phone:571-423-7945
Practice Address - Fax:571-313-0576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014126031223P0300X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty