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General NPI Number Information
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NPI Number | 1720259054
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Entity Type | Organization
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Legal Business Name | FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC
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Dates
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Enumeration Date | 03/14/2008
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Last Update Date | 06/15/2016
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Provider Practice Location Address
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Address Line | 8120 GATEHOUSE RD #3
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City | FALLS CHURCH
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State | VA
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Zip | 22042-1204
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Country | US
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Telephone | 703-573-3687
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Fax | 703-204-0114
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Provider Business Mailing Address
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Address Line | 8120 GATEHOUSE RD #3
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City | FALLS CHURCH
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State | VA
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Zip | 22042-1204
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Country | US
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Telephone | 703-573-3687
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Fax | 703-204-0114
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LAURENCE R O'HALLORAN
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Credential | MD
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Telephone | 703-573-3687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | 0101051134
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License Number State | VA
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