MEDICARE: MERRIFIELD DENTAL GROUP 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	261QD0000X	Dental Clinic/Center
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1790486827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERRIFIELD DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	8310 OLD COURTHOUSE RD STE A
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3872
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 OLD LEE HWY STE 200A
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-4376
Country	:	US
Telephone Number	:	703-945-2200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GEITH KALLAS
Credential	:	DDS
Telephone Number	:	703-622-3300

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	12/18/2023

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