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General NPI Number Information
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NPI Number | 1992117741
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Entity Type | Organization
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Legal Business Name | PREMIER DENTAL ARTS, LLC
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Dates
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Enumeration Date | 05/28/2014
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Last Update Date | 05/28/2014
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Provider Practice Location Address
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Address Line | 4001 FAIR RIDGE DR STE 105
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City | FAIRFAX
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State | VA
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Zip | 22033-2917
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Country | US
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Telephone | 703-865-6276
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Fax | 888-492-5156
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Provider Business Mailing Address
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Address Line | 4001 FAIR RIDGE DR STE 105
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City | FAIRFAX
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State | VA
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Zip | 22033-2917
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Country | US
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Telephone | 703-865-6276
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Fax | 888-492-5156
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Authorized Official
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Title or Position | DENTIST /OWNER
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Name | FAN YU
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Credential | DMD
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Telephone | 703-865-6276
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 0401413342
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License Number State | VA
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