=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225374317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILEY DU DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2012
-----------------------------------------------------
Last Update Date | 12/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3610 FOREST DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22302-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-578-4221
-----------------------------------------------------
Fax | 703-578-1228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3610 FOREST DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22302-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-578-4221
-----------------------------------------------------
Fax | 703-578-1228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KHANH Q DU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 703-578-4221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401413715
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------