Healthcare Provider Details

I. General information

NPI: 1790486827
Provider Name (Legal Business Name): MERRIFIELD DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 12/18/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 OLD LEE HWY STE 200A
FAIRFAX VA
22031-4376
US

IV. Provider business mailing address

8310 OLD COURTHOUSE RD STE A
VIENNA VA
22182-3872
US

V. Phone/Fax

Practice location:
  • Phone: 703-945-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GEITH KALLAS
Title or Position: OWNER
Credential: DDS
Phone: 703-622-3300