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General NPI Number Information
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NPI Number | 1316430598
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Entity Type | Organization
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Legal Business Name | MERRIFIELD PEDIATRIC DENTISTRY PLLC
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Dates
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Enumeration Date | 06/12/2018
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Last Update Date | 06/12/2018
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Provider Practice Location Address
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Address Line | 2301 GALLOWS RD STE 115
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City | DUNN LORING
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State | VA
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Zip | 22027-1149
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Country | US
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Telephone | 571-293-1668
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Fax |
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Provider Business Mailing Address
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Address Line | 2722 MANHATTAN PL
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City | VIENNA
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State | VA
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Zip | 22180-7343
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Country | US
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Telephone | 804-306-4805
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MONAMIE GHATAK
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Credential | DDS
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Telephone | 804-306-4805
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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 | 0401411100
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License Number State | VA
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