Healthcare Provider Details

I. General information

NPI: 1104160639
Provider Name (Legal Business Name): RUBEN DARIO CUELLAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 COLUMBIA PIKE STE 102
ARLINGTON VA
22204-3117
US

IV. Provider business mailing address

5555 COLUMBIA PIKE STE 102
ARLINGTON VA
22204-3117
US

V. Phone/Fax

Practice location:
  • Phone: 703-575-9899
  • Fax: 703-575-9890
Mailing address:
  • Phone: 703-505-1285
  • Fax: 703-575-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413814
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: