Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 0401410503 | VA |
Y | 1223D0004X | Dentist Anesthesiologist | 0401410503 | VA |
NPI | 1396845558 |
---|---|
Provider Name | Wissam Fawzi Ali |
First Address | Springfield, VA 22150-3812 |
Second Address | Springfield, VA 22150-3812 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 10/04/2014 |