Healthcare Provider Details

I. General information

NPI: 1831418714
Provider Name (Legal Business Name): PATRICK R FRIEND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10530 ROSEHAVEN ST STE 111
FAIRFAX VA
22030-2840
US

IV. Provider business mailing address

10530 ROSEHAVEN ST STE 111
FAIRFAX VA
22030-2840
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS040307
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401415111
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: