=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174118723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOCUS DENTAL SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2021
-----------------------------------------------------
Last Update Date | 03/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7617 LITTLE RIVER TPKE STE 910
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-462-9092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7617 LITTLE RIVER TPKE STE 910
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-462-9092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NORACHAI PHISUTHIKUL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-462-9092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0004X
-----------------------------------------------------
Taxonomy Name | Dental Anesthesiology
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------