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General NPI Number Information
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NPI Number | 1639509102
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Entity Type | Organization
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Legal Business Name | OPTIMUM DENTAL
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Dates
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Enumeration Date | 11/20/2013
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Last Update Date | 11/20/2013
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Provider Practice Location Address
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Address Line | 7389 LEE HWY STE 101
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City | FALLS CHURCH
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State | VA
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Zip | 22042-1737
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Country | US
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Telephone | 703-876-4700
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Fax | 703-876-4705
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Provider Business Mailing Address
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Address Line | 7389 LEE HWY STE 101
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City | FALLS CHURCH
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State | VA
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Zip | 22042-1737
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Country | US
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Telephone | 703-876-4700
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Fax | 703-876-4705
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MARCIA WALLER
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Credential |
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Telephone | 703-876-4700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 04041411907
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License Number State | VA
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