Provider Demographics
NPI:1649902396
Name:NEISHABOORY, AMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:AMIN
Middle Name:
Last Name:NEISHABOORY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 WESTPARK DR APT 1915
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4296
Mailing Address - Country:US
Mailing Address - Phone:646-648-2528
Mailing Address - Fax:
Practice Address - Street 1:7911 WESTPARK DR APT 1915
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4296
Practice Address - Country:US
Practice Address - Phone:646-648-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014174351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty