Healthcare Provider Details

I. General information

NPI: 1255817730
Provider Name (Legal Business Name): FUSION DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CHAIN BRIDGE RD
MC LEAN VA
22101-6026
US

IV. Provider business mailing address

1401 CHAIN BRIDGE RD
MC LEAN VA
22101-6026
US

V. Phone/Fax

Practice location:
  • Phone: 703-821-1633
  • Fax:
Mailing address:
  • Phone: 703-821-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number401007478
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number401410040
License Number StateVA

VIII. Authorized Official

Name: JAIME BYERLY
Title or Position: DIRECTOR, OPERATIONS
Credential: DO
Phone: 202-699-1027