MEDICARE: ROLLING VALLEY DENTAL PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401413633	VA

General Provider Information

NPI Number	:	1326476300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROLLING VALLEY DENTAL PLC

Provider Business Mailing Address
First Line	:	6405 SHIPLETT BLVD
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-3446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6373 TRIPS WAY
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-1181
Country	:	US
Telephone Number	:	954-667-8136
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	FAISAL ELHUSSEIN
Credential	:	DMD
Telephone Number	:	954-667-8136

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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