Healthcare Provider Details

I. General information

NPI: 1821621467
Provider Name (Legal Business Name): BLESSED SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5249 DUKE ST STE L-10
ALEXANDRIA VA
22304-2926
US

IV. Provider business mailing address

5249 DUKE ST STE L-10
ALEXANDRIA VA
22304-2926
US

V. Phone/Fax

Practice location:
  • Phone: 703-823-8812
  • Fax: 703-823-8813
Mailing address:
  • Phone: 703-823-8812
  • Fax: 703-823-8813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AILEEN C KIM
Title or Position: DENTIST
Credential: DDS
Phone: 703-823-8812