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General NPI Number Information
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NPI Number | 1316309412
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Entity Type | Organization
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Legal Business Name | DENTAL ASSOCIATES OF NORTHERN VIRGINIA FAIRFAX, PLLC
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Dates
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Enumeration Date | 03/28/2016
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Last Update Date | 03/28/2016
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Provider Practice Location Address
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Address Line | 5417 BACKLICK RD SUITE D
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City | SPRINGFIELD
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State | VA
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Zip | 22151-3915
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Country | US
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Telephone | 703-750-9404
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Fax |
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Provider Business Mailing Address
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Address Line | 5417 BACKLICK RD SUITE D
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City | SPRINGFIELD
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State | VA
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Zip | 22151-3915
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP INSURANCE PLAN MANAGEMENT
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Name | MIKE COLE
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Credential |
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Telephone | 941-955-3150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | VA
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