Provider Demographics
NPI:1023213758
Name:FARDSHISHEH, REZA (DMD)
Entity type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:FARDSHISHEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11359 SUNSET HILLS RD
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5275
Mailing Address - Country:US
Mailing Address - Phone:703-437-6666
Mailing Address - Fax:703-435-8281
Practice Address - Street 1:6120 BRANDON AVE STE 314
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2504
Practice Address - Country:US
Practice Address - Phone:703-569-0002
Practice Address - Fax:703-569-8758
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics