Healthcare Provider Details

I. General information

NPI: 1265369946
Provider Name (Legal Business Name): FAIRFAX CITY DENTIST, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3929 BLENHEIM BLVD STE 91D
FAIRFAX VA
22030-2421
US

IV. Provider business mailing address

3929 BLENHEIM BLVD STE 91D
FAIRFAX VA
22030-2421
US

V. Phone/Fax

Practice location:
  • Phone: 703-385-1617
  • Fax: 703-865-7711
Mailing address:
  • Phone: 703-385-1617
  • Fax: 703-865-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. VLADYSLAV OVCHARENKO
Title or Position: OWNER
Credential:
Phone: 703-385-1617