Provider Demographics
NPI:1295114841
Name:RAVADGAR, SHABNAM (DMD)
Entity type:Individual
Prefix:DR
First Name:SHABNAM
Middle Name:
Last Name:RAVADGAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 ELDEN ST STE 220
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4543
Mailing Address - Country:US
Mailing Address - Phone:703-574-1716
Mailing Address - Fax:703-662-9904
Practice Address - Street 1:494 ELDEN ST STE 220
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4543
Practice Address - Country:US
Practice Address - Phone:703-574-1716
Practice Address - Fax:703-662-9904
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014168351223G0001X
FLDN21136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist