Provider Demographics
NPI:1912637562
Name:ESTAFANOUS PC
Entity Type:Organization
Organization Name:ESTAFANOUS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTAFANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:317-250-0043
Mailing Address - Street 1:13885 HEDGEWOOD DR STE 225
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-7931
Mailing Address - Country:US
Mailing Address - Phone:202-644-8844
Mailing Address - Fax:202-644-8844
Practice Address - Street 1:13885 HEDGEWOOD DR STE 225
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-7931
Practice Address - Country:US
Practice Address - Phone:202-644-8844
Practice Address - Fax:202-644-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center