MEDICARE: POTOMAC MILLS FAMILY DENTAL

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	0401412117	VA

General Provider Information

NPI Number	:	1821434127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTOMAC MILLS FAMILY DENTAL

Provider Business Mailing Address
First Line	:	14338 GIDEON DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-4640
Country	:	US
Telephone Number	:	703-348-8070
Fax Number	:

Provider Business Practice Location Address
First Line	:	14338 GIDEON DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-4640
Country	:	US
Telephone Number	:	703-348-8070
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KERI TRAN
Credential	:	DDS
Telephone Number	:	703-658-3000

Provider Enumeration Date	:	05/14/2013
Last Update Date	:	05/14/2013

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