MEDICARE: RESTON ORAL AND FACIAL SURGERY 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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1639919194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTON ORAL AND FACIAL SURGERY PLLC

Provider Business Mailing Address
First Line	:	1890 PRESTON WHITE DR STE 100
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-5430
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1890 PRESTON WHITE DR STE 100
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-5430
Country	:	US
Telephone Number	:	571-595-3223
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. SUNNY KIM
Credential	:
Telephone Number	:	703-774-6856

Provider Enumeration Date	:	05/30/2024
Last Update Date	:	05/30/2024

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