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General NPI Number Information
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NPI Number | 1831225507
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Entity Type | Organization
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Legal Business Name | FAIR OAKS SKIN CARE CENTER, LTD
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3700 JOSEPH SIEWICK DR SUITE 403
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City | FAIRFAX
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State | VA
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Zip | 22033-1744
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Country | US
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Telephone | 703-648-2488
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Fax | 703-648-2489
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Provider Business Mailing Address
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Address Line | 3700 JOSEPH SIEWICK DR SUITE 403
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City | FAIRFAX
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State | VA
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Zip | 22033-1744
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Country | US
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Telephone | 703-648-2488
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Fax | 703-648-2489
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRENDA DINTIMAN
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Credential | M.D.
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Telephone | 703-648-2488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101046760
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License Number State | VA
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