=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902378557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLIS & LINDGREN ORTHODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2018
-----------------------------------------------------
Last Update Date | 12/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 JOHN MARR DR STE 401
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-750-9393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 JOHN MARR DR STE 401
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-750-9393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. MEGHAN LINDGREN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-750-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------