Healthcare Provider Details

I. General information

NPI: 1720486434
Provider Name (Legal Business Name): DULLES ORAL SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24805 PINEBROOK RD SUITE 100
CHANTILLY VA
20152-4126
US

IV. Provider business mailing address

24805 PINEBROOK RD SUITE 100
CHANTILLY VA
20152-4126
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateVA

VIII. Authorized Official

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