Provider Demographics
NPI:1174764047
Name:FAVAGEHI, JASON FARR (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:FARR
Last Name:FAVAGEHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 OLD COURTHOUSE RD STE C
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3881
Mailing Address - Country:US
Mailing Address - Phone:703-356-1200
Mailing Address - Fax:
Practice Address - Street 1:8304 OLD COURTHOUSE RD STE C
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3881
Practice Address - Country:US
Practice Address - Phone:703-356-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist