MEDICARE: FAIRFAX 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		VA

General Provider Information

NPI Number	:	1710496294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRFAX DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	11351 RANDOM HILLS RD STE 102
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-6081
Country	:	US
Telephone Number	:	703-691-2221
Fax Number	:	703-691-3215

Provider Business Practice Location Address
First Line	:	11351 RANDOM HILLS RD STE 102
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-6081
Country	:	US
Telephone Number	:	703-691-2221
Fax Number	:	703-691-3215

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. SAMUEL SAEHO HAM
Credential	:	DDS
Telephone Number	:	703-691-2221

Provider Enumeration Date	:	09/27/2017
Last Update Date	:	07/21/2022

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