=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710477815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PD DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2018
-----------------------------------------------------
Last Update Date | 05/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10721 MAIN ST STE 100
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-6913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-865-8829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12791 FAIR BRIAR LN
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-3850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-426-4579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PATRICIA DARY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 571-426-4579
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401414585
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------