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General NPI Number Information
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NPI Number | 1497979504
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Entity Type | Organization
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Legal Business Name | FAIRFAX ORTHODONTIC ASSOCIATES, PLLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12011 LEE JACKSON MEMORIAL HWY
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City | FAIRFAX
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State | VA
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Zip | 22033-3310
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Country | US
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Telephone | 703-691-9061
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Fax |
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Provider Business Mailing Address
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Address Line | 12011 LEE JACKSON MEMORIAL HWY
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City | FAIRFAX
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State | VA
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Zip | 22033-3310
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Country | US
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Telephone | 703-691-9061
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. LUCY L. MCCABE
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Credential |
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Telephone | 703-719-5828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 0401007980
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License Number State | VA
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