Healthcare Provider Details

I. General information

NPI: 1053714766
Provider Name (Legal Business Name): FAMILY ORTHODONTICS OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6225 BRANDON AVE STE 170
SPRINGFIELD VA
22150-2525
US

IV. Provider business mailing address

1350 SPRING ST NW STE 600
ATLANTA GA
30309-2870
US

V. Phone/Fax

Practice location:
  • Phone: 404-389-1950
  • Fax: 678-444-4152
Mailing address:
  • Phone: 404-389-1950
  • Fax: 678-444-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401414164
License Number StateVA

VIII. Authorized Official

Name: JEANNINE BARTCH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 404-389-1950