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General NPI Number Information
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NPI Number | 1205338118
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Entity Type | Organization
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Legal Business Name | ASSEFA DEMEWOZ DDS PLLC
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Dates
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Enumeration Date | 03/06/2018
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Last Update Date | 03/06/2018
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Provider Practice Location Address
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Address Line | 7746 GUNSTON PLZ
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City | LORTON
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State | VA
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Zip | 22079-1897
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Country | US
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Telephone | 703-348-6969
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Fax | 540-808-1580
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Provider Business Mailing Address
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Address Line | 7746 GUNSTON PLZ
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City | LORTON
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State | VA
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Zip | 22079-1897
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Country | US
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Telephone | 703-348-6969
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Fax | 540-808-1580
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Authorized Official
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Title or Position | OWNER
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Name | DR. ASSEFA DEMEWOZ
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Credential | DDS
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Telephone | 703-348-6969
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0401413725
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License Number State | VA
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