=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417279589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAXENA DENTAL FAIRFAX, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2010
-----------------------------------------------------
Last Update Date | 02/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3903 FAIR RIDGE DR SUITE 214
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-877-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20023 BELMONT STATION DR
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-6611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-508-4421
-----------------------------------------------------
Fax | 703-953-2392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SUNIL SAXENA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-508-4421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401410456
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------