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General NPI Number Information
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NPI Number | 1558066001
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Entity Type | Organization
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Legal Business Name | DENTAL IMPLANT SPECIALISTS OF VIRGINIA, PC
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Dates
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Enumeration Date | 04/04/2023
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 1500 CORNERSIDE BLVD STE 600
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City | TYSONS
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State | VA
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Zip | 22182-2441
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Country | US
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Telephone | 703-620-3040
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Fax |
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Provider Business Mailing Address
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Address Line | 3500 MAPLE AVE STE 1600
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City | DALLAS
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State | TX
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Zip | 75219-3936
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Country | US
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Telephone | 909-732-0191
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | MIKE GOLPA
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Credential |
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Telephone | 702-768-7840
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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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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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Taxonomy #3
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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 |
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