Healthcare Provider Details

I. General information

NPI: 1396812004
Provider Name (Legal Business Name): ELIDIA CARNEIRO FIDEL D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 COLUMBIA PIKE SUITE 102
ARLINGTON VA
22204-5852
US

IV. Provider business mailing address

5555 COLUMBIA PIKE SUITE 102
ARLINGTON VA
22204-5852
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5886
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: