Healthcare Provider Details

I. General information

NPI: 1760673214
Provider Name (Legal Business Name): MCLEAN ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 CHAIN BRIDGE RD SUITE 206
MC LEAN VA
22101-4451
US

IV. Provider business mailing address

10440 NEW ASCOT DR
GREAT FALLS VA
22066-3421
US

V. Phone/Fax

Practice location:
  • Phone: 703-893-8800
  • Fax: 703-893-8845
Mailing address:
  • Phone: 703-893-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number3844
License Number StateVA

VIII. Authorized Official

Name: DR. ERIC A FORETICH
Title or Position: OWNER
Credential: D.D.S., M.A.
Phone: 703-893-8800