Provider Demographics
NPI:1578309696
Name:SANJIDEH, TABASOM (DMD, MMS)
Entity type:Individual
Prefix:DR
First Name:TABASOM
Middle Name:
Last Name:SANJIDEH
Suffix:
Gender:F
Credentials:DMD, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21759 GADWALL SQUARE
Mailing Address - Street 2:#F
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147
Mailing Address - Country:US
Mailing Address - Phone:571-437-4409
Mailing Address - Fax:
Practice Address - Street 1:10051 MARKET CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2120
Practice Address - Country:US
Practice Address - Phone:703-214-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014190471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice