Healthcare Provider Details

I. General information

NPI: 1881163699
Provider Name (Legal Business Name): LOUDOUN CENTER FOR ORAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46161 WESTLAKE DR STE 200
STERLING VA
20165-5871
US

IV. Provider business mailing address

46161 WESTLAKE DR STE 200
STERLING VA
20165-5871
US

V. Phone/Fax

Practice location:
  • Phone: 703-544-9740
  • Fax: 703-544-9741
Mailing address:
  • Phone: 703-544-9740
  • Fax: 703-544-9741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON BAE
Title or Position: OWNER/ SURGEON
Credential: DDS, MD
Phone: 703-544-9740