Provider Demographics
NPI:1831573575
Name:SHAHIDI, AFSANEH SAMATHA (DDS)
Entity type:Individual
Prefix:DR
First Name:AFSANEH
Middle Name:SAMATHA
Last Name:SHAHIDI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SAMANEH
Other - Middle Name:ARFAEI
Other - Last Name:SHAHIDI ZADEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8323
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:703-680-7953
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8322
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL7651223G0001X
VA0401415343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid