MEDICARE: FAIRFAX DENTAL PARTNERS, PC

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

General Provider Information

NPI Number	:	1629754726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRFAX DENTAL PARTNERS, PC

Provider Business Mailing Address
First Line	:	10529 BRADDOCK RD STE A
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-2245
Country	:	US
Telephone Number	:	703-250-2970
Fax Number	:

Provider Business Practice Location Address
First Line	:	10529 BRADDOCK RD STE A
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-2245
Country	:	US
Telephone Number	:	703-250-2970
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. DANA MARIE COLASANTO
Credential	:
Telephone Number	:	571-331-5619

Provider Enumeration Date	:	06/23/2023
Last Update Date	:	06/23/2023

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