MEDICARE: LAFAYETTE FAMILY DENTISTRY, PLLC

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	1223G0001X	General Practice Dentistry	0401411128	VA

General Provider Information

NPI Number	:	1578704797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAFAYETTE FAMILY DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	#1225
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-378-1177
Fax Number	:	703-378-1170

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	#1225
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-378-1177
Fax Number	:	703-378-1170

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TRUC T PHAN
Credential	:	D.D.S
Telephone Number	:	703-378-1177

Provider Enumeration Date	:	03/18/2009
Last Update Date	:	03/18/2009

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