Provider Demographics
NPI:1528396330
Name:AESTHETIC DENTISTRY OF LORTON
Entity type:Organization
Organization Name:AESTHETIC DENTISTRY OF LORTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-339-5090
Mailing Address - Street 1:7764 ARMISTEAD ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1918
Mailing Address - Country:US
Mailing Address - Phone:703-339-5090
Mailing Address - Fax:703-339-1068
Practice Address - Street 1:7764 ARMISTEAD ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1918
Practice Address - Country:US
Practice Address - Phone:703-339-5090
Practice Address - Fax:703-339-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014105741223E0200X
VA44771223G0001X
VA59971223G0001X
VA0402203732124Q00000X
VA0402002410124Q00000X
VA04014114771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902221OtherUCCI