Healthcare Provider Details

I. General information

NPI: 1497101240
Provider Name (Legal Business Name): ELITE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 N FILLMORE ST C
ARLINGTON VA
22201-6701
US

IV. Provider business mailing address

1025 N FILLMORE ST C
ARLINGTON VA
22201-6701
US

V. Phone/Fax

Practice location:
  • Phone: 703-243-4500
  • Fax: 703-243-4700
Mailing address:
  • Phone: 703-243-4500
  • Fax: 703-243-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414811
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412031
License Number StateVA

VIII. Authorized Official

Name: ANNE WEIH
Title or Position: COO
Credential: MHA
Phone: 703-577-4317