Healthcare Provider Details

I. General information

NPI: 1649637828
Provider Name (Legal Business Name): VIRGINIA CENTER FOR COSMETIC AND GENERAL DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 N FILLMORE ST SUITE A
ARLINGTON VA
22201-6701
US

IV. Provider business mailing address

1025 N FILLMORE ST SUITE A
ARLINGTON VA
22201-6701
US

V. Phone/Fax

Practice location:
  • Phone: 703-243-7744
  • Fax: 703-243-7745
Mailing address:
  • Phone: 703-243-7744
  • Fax: 703-243-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414929
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401415308
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401415279
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413869
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414367
License Number StateVA

VIII. Authorized Official

Name: MS. ANNE CHRISTINE HETZ
Title or Position: PRACTICE ADMINISTRATOR
Credential: MHA
Phone: 703-577-4317