MEDICARE: NOVA CENTER FOR DENTAL SLEEP TREATMENT 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	122300000X	Dentist	0401008829	VA

General Provider Information

NPI Number	:	1740659044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA CENTER FOR DENTAL SLEEP TREATMENT PLLC

Provider Business Mailing Address
First Line	:	2810 OLD LEE HWY
Second Line	:	STE 200A
City	:	FAIRFAX
State	:	VA
Zip	:	22031-4376
Country	:	US
Telephone Number	:	703-559-3419
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 OLD LEE HWY
Second Line	:	STE 200A
City	:	FAIRFAX
State	:	VA
Zip	:	22031-4376
Country	:	US
Telephone Number	:	703-559-3419
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. GEITH KALLAS
Credential	:
Telephone Number	:	703-559-3419

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	09/17/2015

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