Healthcare Provider Details

I. General information

NPI: 1578766036
Provider Name (Legal Business Name): KEVIN WADE TOMS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9070 DEVLIN RD #140
BRISTOW VA
20136-1041
US

IV. Provider business mailing address

9070 DEVLIN RD #140
BRISTOW VA
20136-1041
US

V. Phone/Fax

Practice location:
  • Phone: 703-495-3124
  • Fax:
Mailing address:
  • Phone: 703-495-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number054846
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401411454
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: