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General NPI Number Information
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NPI Number | 1740886860
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Entity Type | Organization
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Legal Business Name | GRACEFUL SMILES LLC
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Dates
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Enumeration Date | 12/05/2020
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Last Update Date | 12/05/2020
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Provider Practice Location Address
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Address Line | 6120 BRANDON AVE STE 317
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City | SPRINGFIELD
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State | VA
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Zip | 22150-2504
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Country | US
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Telephone | 703-451-3303
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Fax |
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Provider Business Mailing Address
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Address Line | 6120 BRANDON AVE STE 317
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City | SPRINGFIELD
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State | VA
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Zip | 22150-2504
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Country | US
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Telephone | 703-451-3303
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | ANDREW KIM
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Credential |
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Telephone | 703-677-7202
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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 |
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License Number State |
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