Provider Demographics
NPI:1992117741
Name:PREMIER DENTAL ARTS, LLC
Entity type:Organization
Organization Name:PREMIER DENTAL ARTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST /OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-865-6276
Mailing Address - Street 1:4001 FAIR RIDGE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2917
Mailing Address - Country:US
Mailing Address - Phone:703-865-6276
Mailing Address - Fax:888-492-5156
Practice Address - Street 1:4001 FAIR RIDGE DR STE 105
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-865-6276
Practice Address - Fax:888-492-5156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413342305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization