Healthcare Provider Details

I. General information

NPI: 1639460504
Provider Name (Legal Business Name): NORTHERN VIRGINIA ENDODONTIC ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 FAIRFAX DR SUITE 440
ARLINGTON VA
22203-1772
US

IV. Provider business mailing address

1105 RUSSELL RD
ALEXANDRIA VA
22301-2436
US

V. Phone/Fax

Practice location:
  • Phone: 267-252-0125
  • Fax:
Mailing address:
  • Phone: 267-252-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401412778
License Number StateVA

VIII. Authorized Official

Name: DR. ROBERT A CHERON
Title or Position: MANAGING MEMBER
Credential: DMD, MS
Phone: 267-252-0125