Healthcare Provider Details

I. General information

NPI: 1861497091
Provider Name (Legal Business Name): RICHARD F. DONOHUE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/08/2007
Certification Date:
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: 703-503-2817
Mailing address:
  • Phone: 703-250-2970
  • Fax: 703-503-2817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401004626
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: