Provider Demographics
NPI:1316309412
Name:DENTAL ASSOCIATES OF NORTHERN VIRGINIA FAIRFAX, PLLC
Entity type:Organization
Organization Name:DENTAL ASSOCIATES OF NORTHERN VIRGINIA FAIRFAX, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-955-3150
Mailing Address - Street 1:5417 BACKLICK RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5417 BACKLICK RD
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3915
Practice Address - Country:US
Practice Address - Phone:703-750-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty