1073887741 NPI number — SAMAN MADANI DMD & SHADI SHAREGHI DDS PC

Table of content: (NPI 1073887741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073887741 NPI number — SAMAN MADANI DMD & SHADI SHAREGHI DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMAN MADANI DMD & SHADI SHAREGHI DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNNY SMILES PEDIATRIC AND FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073887741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3930 PENDER DR
Provider Second Line Business Mailing Address:
SUITE #250
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-0985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-865-5779
Provider Business Mailing Address Fax Number:
703-865-5543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3930 PENDER DR
Provider Second Line Business Practice Location Address:
SUITE #250
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-0985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-865-5779
Provider Business Practice Location Address Fax Number:
703-865-5543
Provider Enumeration Date:
02/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MADANI
Authorized Official First Name:
SAMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
703-865-5779

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0401410760 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 0401412634 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CX014 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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