MEDICARE: GAINESVILLE ORTHODONTIC ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	0401003534	VA

General Provider Information

NPI Number	:	1073749966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAINESVILLE ORTHODONTIC ASSOCIATES

Provider Business Mailing Address
First Line	:	7504 IRON BAR LN
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-2999
Country	:	US
Telephone Number	:	703-719-5828
Fax Number	:	703-691-9061

Provider Business Practice Location Address
First Line	:	7504 IRON BAR LN
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-2999
Country	:	US
Telephone Number	:	703-719-5828
Fax Number	:	703-691-9061

Authorized Official
Title or Position	:	GM
Name	:	LUCY LYNN MCCABE
Credential	:
Telephone Number	:	703-719-9192

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	06/05/2009

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