Provider Demographics
NPI:1093186512
Name:DACZKOWSKI ORTHODONTICS
Entity Type:Organization
Organization Name:DACZKOWSKI ORTHODONTICS
Other - Org Name:DR D'S SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TELISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KIDD-WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-361-4278
Mailing Address - Street 1:8715 STONEWALL ROAD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-361-4278
Mailing Address - Fax:703-361-2449
Practice Address - Street 1:8715 STONEWALL ROAD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-361-4278
Practice Address - Fax:703-361-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty