Healthcare Provider Details

I. General information

NPI: 1326799545
Provider Name (Legal Business Name): BRISTOW ENDODONTIC ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9070 DEVLIN RD STE 140
BRISTOW VA
20136-1042
US

IV. Provider business mailing address

400 N VIEW TER
ALEXANDRIA VA
22301-2612
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 Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT A CHERON
Title or Position: MANAGING MEMBER
Credential: DMD, MS
Phone: 703-528-8382