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General NPI Number Information
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NPI Number | 1669772901
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Entity Type | Organization
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Legal Business Name | ADVANCED COSMETIC DENTISTRY OF NOVA
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 11/02/2010
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Provider Practice Location Address
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Address Line | 3903 FAIR RIDGE DR SUITE # 212
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City | FAIRFAX
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State | VA
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Zip | 22033-2943
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Country | US
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Telephone | 703-865-6880
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Fax |
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Provider Business Mailing Address
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Address Line | 3903 FAIR RIDGE DR SUITE # 212
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City | FAIRFAX
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State | VA
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Zip | 22033-2943
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Country | US
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Telephone | 703-865-6880
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNIFER KIM
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Credential | DMD
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Telephone | 703-865-6880
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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 | 0401412307
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License Number State | VA
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