Provider Demographics
NPI:1881968204
Name:AMIRSAYAFI, PAYAM
Entity type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:AMIRSAYAFI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 GARRISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-1843
Mailing Address - Country:US
Mailing Address - Phone:540-318-5577
Mailing Address - Fax:540-369-6250
Practice Address - Street 1:1003 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-1843
Practice Address - Country:US
Practice Address - Phone:540-318-5577
Practice Address - Fax:540-369-6250
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014133231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1881968204Medicaid