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General NPI Number Information
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NPI Number | 1497186068
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Entity Type | Organization
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Legal Business Name | MEDICAL MANAGEMENT OF VA
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Dates
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Enumeration Date | 12/09/2013
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Last Update Date | 12/09/2013
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Provider Practice Location Address
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Address Line | 11230 WAPLES MILL RD SUITE 125
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City | FAIRFAX
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State | VA
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Zip | 22030-6087
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Country | US
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Telephone | 703-246-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 11230 WAPLES MILL RD SUITE 125
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City | FAIRFAX
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State | VA
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Zip | 22030
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Country | US
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Telephone | 703-246-9355
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ CEO
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Name | MR. PETER EWENS
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Credential |
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Telephone | 703-246-9355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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