Healthcare Provider Details

I. General information

NPI: 1588867113
Provider Name (Legal Business Name): VIRIGINIA ORAL FACIAL & IMPLANT SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2007
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 LEWINSVILLE RD SUITE 203
MCLEAN VA
22102-2814
US

IV. Provider business mailing address

PO BOX 1049
FAYETTEVILLE AR
72702-1049
US

V. Phone/Fax

Practice location:
  • Phone: 703-388-2805
  • Fax: 703-388-2806
Mailing address:
  • Phone: 479-464-5824
  • Fax: 479-725-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0401411538
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number0401411538
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411538
License Number StateVA

VIII. Authorized Official

Name: DR. MICHAEL TIMOTHY GOCKE
Title or Position: OWNER
Credential: DDS
Phone: 703-388-2805