Healthcare Provider Details

I. General information

NPI: 1295396018
Provider Name (Legal Business Name): MARY JO DELAHUNT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 FORT EVANS RD NE
LEESBURG VA
20176-4420
US

IV. Provider business mailing address

143 MEADOWS LN NE
LEESBURG VA
20176-4446
US

V. Phone/Fax

Practice location:
  • Phone: 703-443-2000
  • Fax:
Mailing address:
  • Phone: 434-660-8149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402207850
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: