Healthcare Provider Details

I. General information

NPI: 1851962757
Provider Name (Legal Business Name): JESSICA KOCAN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22855 BRAMBLETON PLZ STE 200
BRAMBLETON VA
20148-4871
US

IV. Provider business mailing address

700 N RANDOLPH ST APT 1200
ARLINGTON VA
22203-2188
US

V. Phone/Fax

Practice location:
  • Phone: 703-327-1718
  • Fax:
Mailing address:
  • Phone: 814-881-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401417320
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: