Provider Demographics
NPI:1063898427
Name:GALLERIA DENTAL AESTHETICS
Entity type:Organization
Organization Name:GALLERIA DENTAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-448-1020
Mailing Address - Street 1:1600 TYSONS BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4865
Mailing Address - Country:US
Mailing Address - Phone:703-448-1020
Mailing Address - Fax:703-448-2442
Practice Address - Street 1:1600 TYSONS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4865
Practice Address - Country:US
Practice Address - Phone:703-448-1020
Practice Address - Fax:703-448-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010061411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty