Healthcare Provider Details

I. General information

NPI: 1275446114
Provider Name (Legal Business Name): ADRIAN RYCZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 WALNUT ST STE 240
FAIRFAX VA
22030-4738
US

IV. Provider business mailing address

615 SWANN AVE APT 430
ALEXANDRIA VA
22301-1461
US

V. Phone/Fax

Practice location:
  • Phone: 703-638-1420
  • Fax:
Mailing address:
  • Phone: 856-952-0165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420269
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: