Healthcare Provider Details

I. General information

NPI: 1184791758
Provider Name (Legal Business Name): JEFFREY IRA KLIOZE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9607 PEMBERLY LN
FAIRFAX STATION VA
22039-3234
US

IV. Provider business mailing address

9607 PEMBERLY LN
FAIRFAX STATION VA
22039-3234
US

V. Phone/Fax

Practice location:
  • Phone: 703-493-8488
  • Fax:
Mailing address:
  • Phone: 703-493-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401007694
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: