Healthcare Provider Details

I. General information

NPI: 1639172620
Provider Name (Legal Business Name): MICHAEL EDWIN OPPENHEIMER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9938 MAIN ST
FAIRFAX VA
22031-3901
US

IV. Provider business mailing address

9938 MAIN ST
FAIRFAX VA
22031-3901
US

V. Phone/Fax

Practice location:
  • Phone: 703-591-6700
  • Fax: 703-691-0686
Mailing address:
  • Phone: 703-591-6700
  • Fax: 703-691-0686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6369
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: