Provider Demographics
NPI:1023555760
Name:NORTHERN VIRGINIA PERIODONTICS, PLLC.
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA PERIODONTICS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:CARLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD, PC
Authorized Official - Phone:703-534-1766
Mailing Address - Street 1:103 W BROAD ST
Mailing Address - Street 2:STE. 601
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4235
Mailing Address - Country:US
Mailing Address - Phone:703-534-1766
Mailing Address - Fax:703-534-1976
Practice Address - Street 1:103 W BROAD ST
Practice Address - Street 2:STE. 601
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4235
Practice Address - Country:US
Practice Address - Phone:703-534-1766
Practice Address - Fax:703-534-1976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty