Healthcare Provider Details

I. General information

NPI: 1356480552
Provider Name (Legal Business Name): JAKLIN BEZIK D.D.S., M.D.S.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11150 FAIRFAX BLVD 301
FAIRFAX VA
22030-5066
US

IV. Provider business mailing address

7073 IDYLWOOD RD
FALLS CHURCH VA
22043-1527
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-4474
  • Fax: 703-934-4705
Mailing address:
  • Phone: 703-448-3760
  • Fax: 703-448-3760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401410580
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN1000297
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: