=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912110800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRED A BUBERNAK DDS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1972 OPITZ BLVD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-494-2545
-----------------------------------------------------
Fax | 703-497-1272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1972 OPITZ BLVD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-494-2545
-----------------------------------------------------
Fax | 703-497-1272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. FRED ALBERT BUBERNAK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-494-2545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 05126
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------