Healthcare Provider Details

I. General information

NPI: 1700547932
Provider Name (Legal Business Name): PDC PEDIATRIC DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9901 FAIRFAX BLVD
FAIRFAX VA
22030-1740
US

IV. Provider business mailing address

9901 FAIRFAX BLVD
FAIRFAX VA
22030-1740
US

V. Phone/Fax

Practice location:
  • Phone: 703-383-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL COLE
Title or Position: VP INSURANCE PLAN MANAGEMENT
Credential:
Phone: 727-424-2990