Healthcare Provider Details

I. General information

NPI: 1629754726
Provider Name (Legal Business Name): FAIRFAX DENTAL PARTNERS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10529 BRADDOCK RD STE A
FAIRFAX VA
22032-2245
US

IV. Provider business mailing address

10529 BRADDOCK RD STE A
FAIRFAX VA
22032-2245
US

V. Phone/Fax

Practice location:
  • Phone: 703-250-2970
  • Fax:
Mailing address:
  • Phone: 703-250-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. DANA MARIE COLASANTO
Title or Position: MANAGER
Credential:
Phone: 571-331-5619