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Provider Information for 1659505196

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1659505196

Calendar   Last Updated:  2011-07-11
  Certification Date: 


Name Value
NPI 1659505196
Enumeration Date 2009-05-13
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 4927 TALLOWWOOD DR
MONTCLAIR, VA 22025-3031
United States

Phone: 734-395-3457 | Fax:
View Map External Link
Primary Practice Address 12581 MILSTEAD WAY SUITE 204
WOODBRIDGE, VA 22192-5445
United States

Phone: 571-285-2577 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice VA 0401411660
No 1223G0001X - Dentist General Practice MD 13654