Healthcare Provider Details

I. General information

NPI: 1306424304
Provider Name (Legal Business Name): ISAAC SO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 FAIRFAX CORNER AVE W STE 215
FAIRFAX VA
22030-8627
US

IV. Provider business mailing address

4460 BLACK IRONWOOD DR
FAIRFAX VA
22030-9068
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-8640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419807
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000553
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: