Healthcare Provider Details

I. General information

NPI: 1720821523
Provider Name (Legal Business Name): BDG SPECIALTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE STE 314
SPRINGFIELD VA
22150-2504
US

IV. Provider business mailing address

3807 GLENBROOK RD
FAIRFAX VA
22031-3105
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: AILEEN CHYN KIM
Title or Position: OWNER
Credential:
Phone: 703-677-7202