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General NPI Number Information
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NPI Number | 1689076747
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Entity Type | Organization
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Legal Business Name | VIENNA DERMATOLOGY, LLC
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Dates
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Enumeration Date | 09/20/2014
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Last Update Date | 09/20/2014
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Provider Practice Location Address
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Address Line | 410 MAPLE AVE W STE 3
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City | VIENNA
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State | VA
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Zip | 22180-4224
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Country | US
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Telephone | 703-281-3626
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Fax | 703-281-3615
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Provider Business Mailing Address
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Address Line | 410 MAPLE AVE W STE 3
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City | VIENNA
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State | VA
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Zip | 22180-4224
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Country | US
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Telephone | 703-281-3626
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Fax | 703-281-3615
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. MAI HOANG NGUYEN
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Credential | M.D.
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Telephone | 703-281-3626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0101244058
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License Number State | VA
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