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General NPI Number Information
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NPI Number | 1902207327
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Entity Type | Organization
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Legal Business Name | GOOSE CREEK VILLAGE DENTAL
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Dates
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Enumeration Date | 09/05/2014
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Last Update Date | 09/05/2014
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Provider Practice Location Address
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Address Line | 21001 SYCOLIN RD SUITE 240
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City | ASHBURN
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State | VA
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Zip | 20147-4073
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Country | US
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Telephone | 703-723-4224
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Fax | 703-723-4220
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Provider Business Mailing Address
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Address Line | 21001 SYCOLIN RD SUITE 240
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City | ASHBURN
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State | VA
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Zip | 20147-4073
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Country | US
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Telephone | 703-723-4224
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Fax | 703-723-4220
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Authorized Official
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Title or Position | DENTIST / PARTNER
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Name | MICHAEL H KIM
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Credential | DDS
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Telephone | 703-723-4224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0401413573
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License Number State | VA
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