Provider Demographics
NPI:1932604501
Name:ITANI, AMIR (DDS)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:ITANI
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 1:700 N RANDOLPH ST APT 1200
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-2188
Mailing Address - Country:US
Mailing Address - Phone:240-393-2606
Mailing Address - Fax:
Practice Address - Street 1:4701 RANDOLPH RD STE G10
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2259
Practice Address - Country:US
Practice Address - Phone:301-468-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN20001211223S0112X
MD173031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery