MEDICARE: DR. SHIRLEY F BETHEL D.M.D

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	1223P0221X	Pediatric Dentistry	0401007521	VA

General Provider Information

NPI Number	:	1548456106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHIRLEY F BETHEL D.M.D

Provider Business Mailing Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1400
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-378-2000
Fax Number	:	703-378-2400

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1400
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-378-2000
Fax Number	:	703-378-2400

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	12/20/2012

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