=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912473505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA THAI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2018
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20405 EXCHANGE ST STE 210
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-5934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-729-0169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25055 RIDING PLZ STE 110
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20152-5918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401416212
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------