Healthcare Provider Details

I. General information

NPI: 1710907134
Provider Name (Legal Business Name): FAIRFAX ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10530 ROSEHAVEN ST SUITE 111
FAIRFAX VA
22030-2840
US

IV. Provider business mailing address

10530 ROSEHAVEN ST SUITE 111
FAIRFAX VA
22030-2840
US

V. Phone/Fax

Practice location:
  • Phone: 703-385-5777
  • Fax: 703-591-5386
Mailing address:
  • Phone: 703-385-5777
  • Fax: 703-591-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JULIA M SPRADLIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 703-385-5777