Provider Demographics
NPI:1285293209
Name:DEHYAR, ELHAM
Entity type:Individual
Prefix:
First Name:ELHAM
Middle Name:
Last Name:DEHYAR
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 1:24686 LENAH RD
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2324
Mailing Address - Country:US
Mailing Address - Phone:703-332-1863
Mailing Address - Fax:
Practice Address - Street 1:12989 FAIR LAKES SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-5177
Practice Address - Country:US
Practice Address - Phone:703-222-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416546122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist