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General NPI Number Information
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NPI Number | 1700212511
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Entity Type | Organization
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Legal Business Name | GRACE DENTAL OF VIRGINIA, LLC
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 4530 WALNEY RD SUITE 102
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City | CHANTILLY
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State | VA
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Zip | 20151-2284
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Country | US
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Telephone | 703-870-7784
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Fax |
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Provider Business Mailing Address
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Address Line | 4530 WALNEY RD SUITE 102
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City | CHANTILLY
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State | VA
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Zip | 20151-2284
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Country | US
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Telephone | 703-870-7784
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SAMER JARWA
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Credential |
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Telephone | 703-870-7784
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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 | 0401412081
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License Number State | VA
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