Healthcare Provider Details

I. General information

NPI: 1871694380
Provider Name (Legal Business Name): JACK WEIL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 MAPLE AVE WEST SUITE B
VIENNA VA
22180
US

IV. Provider business mailing address

402 MAPLE AVE WEST SUITE B
VIENNA VA
22180
US

V. Phone/Fax

Practice location:
  • Phone: 703-255-2573
  • Fax: 703-255-2278
Mailing address:
  • Phone: 703-255-2573
  • Fax: 703-255-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401005551
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: