Healthcare Provider Details

I. General information

NPI: 1558224378
Provider Name (Legal Business Name): LAKE RIDGE PEDIATRIC DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 OLD BRIDGE RD STE 101
WOODBRIDGE VA
22192-2491
US

IV. Provider business mailing address

2080 OLD BRIDGE RD STE 101
WOODBRIDGE VA
22192-2491
US

V. Phone/Fax

Practice location:
  • Phone: 571-398-0672
  • Fax:
Mailing address:
  • Phone: 571-398-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: FADI SALEH
Title or Position: OWNER
Credential: DDS
Phone: 571-398-0672