Provider Demographics
NPI:1295157501
Name:THE TOOTH DOC FAMILY DENTISTRY
Entity type:Organization
Organization Name:THE TOOTH DOC FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:IMANEY
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-793-0291
Mailing Address - Street 1:2465 CENTREVILLE RD
Mailing Address - Street 2:STE J-15
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-4586
Mailing Address - Country:US
Mailing Address - Phone:703-793-0291
Mailing Address - Fax:703-793-0292
Practice Address - Street 1:2465 CENTREVILLE RD
Practice Address - Street 2:STE J-15
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-4586
Practice Address - Country:US
Practice Address - Phone:703-793-0291
Practice Address - Fax:703-793-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty