Provider Demographics
NPI:1629855226
Name:IMAD, MARIE MICHELLE
Entity type:Individual
Prefix:
First Name:MARIE MICHELLE
Middle Name:
Last Name:IMAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8605 WESTWOOD CENTER DR
Mailing Address - Street 2:#200
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8605 WESTWOOD CENTER DR #200
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182
Practice Address - Country:US
Practice Address - Phone:703-942-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2024-08-13
Deactivation Date:2024-04-10
Deactivation Code:
Reactivation Date:2024-06-18
Provider Licenses
StateLicense IDTaxonomies
VA04014190981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice