Provider Demographics
NPI:1386910529
Name:LET'S SMILE OF FAIRFAX PLLC
Entity type:Organization
Organization Name:LET'S SMILE OF FAIRFAX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:YOUSEF
Authorized Official - Last Name:GHATRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-719-5828
Mailing Address - Street 1:4210 FAIRFAX CORNER AVE W
Mailing Address - Street 2:SUITE 245
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8619
Mailing Address - Country:US
Mailing Address - Phone:703-719-5828
Mailing Address - Fax:703-691-8877
Practice Address - Street 1:4210 FAIRFAX CORNER AVE W
Practice Address - Street 2:SUITE 245
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8619
Practice Address - Country:US
Practice Address - Phone:703-719-5828
Practice Address - Fax:703-691-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007980305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service