Healthcare Provider Details

I. General information

NPI: 1477337640
Provider Name (Legal Business Name): AESTHETIC DERMATOLOGY AND MOHS SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2826 OLD LEE HWY STE 150
FAIRFAX VA
22031-4323
US

IV. Provider business mailing address

2826 OLD LEE HWY STE 150
FAIRFAX VA
22031-4323
US

V. Phone/Fax

Practice location:
  • Phone: 571-529-5600
  • Fax: 571-529-5656
Mailing address:
  • Phone: 571-529-5600
  • Fax: 571-529-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM JON TINKLEPAUGH
Title or Position: DERMATOLOGIST/OWNER
Credential: MD
Phone: 571-529-5600