Provider Demographics
NPI:1073990594
Name:PRESTIGE DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:PRESTIGE DENTAL SPECIALISTS
Other - Org Name:CENTER FOR DENTOFACIAL AESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORACHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHISUTHIKUL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-256-2556
Mailing Address - Street 1:7630 LITTLE RIVER TPKE
Mailing Address - Street 2:115
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2610
Mailing Address - Country:US
Mailing Address - Phone:703-256-2556
Mailing Address - Fax:
Practice Address - Street 1:7630 LITTLE RIVER TPKE
Practice Address - Street 2:115
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2610
Practice Address - Country:US
Practice Address - Phone:703-256-2556
Practice Address - Fax:703-256-7722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty