Healthcare Provider Details

I. General information

NPI: 1992011233
Provider Name (Legal Business Name): DULLES ORAL SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24805 PINEBROOK RD STE 100
CHANTILLY VA
20152-4127
US

IV. Provider business mailing address

24805 PINEBROOK RD STE 100
CHANTILLY VA
20152-4127
US

V. Phone/Fax

Practice location:
  • Phone: 703-327-0955
  • Fax: 703-327-0956
Mailing address:
  • Phone: 703-327-0955
  • Fax: 703-327-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0438000264
License Number StateVA

VIII. Authorized Official

Name: EDWARD AUDUBORN LONGWE
Title or Position: DIRECTOR
Credential: DDS
Phone: 703-327-0955