Provider Demographics
NPI:1750616694
Name:FLORA B. TAJALLI DDS PC
Entity type:Organization
Organization Name:FLORA B. TAJALLI DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:B
Authorized Official - Last Name:TAJALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-709-0102
Mailing Address - Street 1:209 ELDEN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4852
Mailing Address - Country:US
Mailing Address - Phone:703-709-0102
Mailing Address - Fax:703-709-6916
Practice Address - Street 1:209 ELDEN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4852
Practice Address - Country:US
Practice Address - Phone:703-709-0102
Practice Address - Fax:703-709-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty