Provider Demographics
NPI:1447818919
Name:BRISTOW FOUNTAIN DENTISTRY, PC
Entity type:Organization
Organization Name:BRISTOW FOUNTAIN DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHARIFIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-565-2920
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10283 BRISTOW CENTER DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2240
Practice Address - Country:US
Practice Address - Phone:703-565-2920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty