Healthcare Provider Details

I. General information

NPI: 1942568258
Provider Name (Legal Business Name): VIRGINIA ORTHODONTICS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MAPLE AVE W STE 440
VIENNA VA
22180-4301
US

IV. Provider business mailing address

301 MAPLE AVE W STE 440
VIENNA VA
22180-4301
US

V. Phone/Fax

Practice location:
  • Phone: 703-539-9166
  • Fax:
Mailing address:
  • Phone: 703-539-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401412796
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401412701
License Number StateVA

VIII. Authorized Official

Name: EUNYOUNG KIM
Title or Position: DR
Credential:
Phone: 703-539-9166