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General NPI Number Information
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NPI Number | 1588144125
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Entity Type | Organization
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Legal Business Name | ELLIS ORTHODONTICS PC
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 4600 JOHN MARR DR STE 401
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City | ANNANDALE
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State | VA
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Zip | 22003-3310
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Country | US
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Telephone | 703-750-9393
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Fax | 703-750-5420
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Provider Business Mailing Address
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Address Line | 4600 JOHN MARR DR STE 401
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City | ANNANDALE
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State | VA
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Zip | 22003-3310
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Country | US
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Telephone | 703-750-9393
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Fax | 703-750-5420
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Authorized Official
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Title or Position | OWNER
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Name | MEGHAN LINDGREN
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Credential | DDS
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Telephone | 703-950-9393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 040141131
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License Number State | VA
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