Provider Demographics
NPI:1194450551
Name:MORTAZAVI, MAHSASADAT
Entity type:Individual
Prefix:
First Name:MAHSASADAT
Middle Name:
Last Name:MORTAZAVI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 TYSONS CENTRAL ST APT 2407
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-6058
Mailing Address - Country:US
Mailing Address - Phone:510-333-1711
Mailing Address - Fax:
Practice Address - Street 1:6505 SYDENSTRICKER RD STE B
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-4282
Practice Address - Country:US
Practice Address - Phone:703-691-5343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014177461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics