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General NPI Number Information
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NPI Number | 1255817730
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Entity Type | Organization
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Legal Business Name | FUSION DENTAL
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 07/17/2018
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Provider Practice Location Address
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Address Line | 1401 CHAIN BRIDGE RD
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City | MC LEAN
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State | VA
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Zip | 22101-6026
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Country | US
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Telephone | 703-821-1633
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 CHAIN BRIDGE RD
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City | MC LEAN
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State | VA
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Zip | 22101-6026
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Country | US
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Telephone | 703-821-1633
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Fax |
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Authorized Official
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Title or Position | DIRECTOR, OPERATIONS
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Name | JAIME BYERLY
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Credential | DO
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Telephone | 202-699-1027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 401410040
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 401007478
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License Number State | VA
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