MEDICARE: DENTISTS OF BRISTOW

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	:	1811782667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTS OF BRISTOW

Provider Business Mailing Address
First Line	:	12701 BRAEMAR VILLAGE PLZ
Second Line	:
City	:	BRISTOW
State	:	VA
Zip	:	20136-5501
Country	:	US
Telephone Number	:	571-500-7411
Fax Number	:

Provider Business Practice Location Address
First Line	:	12701 BRAEMAR VILLAGE PLZ
Second Line	:
City	:	BRISTOW
State	:	VA
Zip	:	20136-5501
Country	:	US
Telephone Number	:	571-500-7411
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DENTISTS OF BRISTOW
Credential	:
Telephone Number	:	571-500-7411

Provider Enumeration Date	:	04/11/2025
Last Update Date	:	06/17/2026

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Directions to “DENTISTS OF BRISTOW ” Practice Location

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