Provider Demographics
NPI:1245421122
Name:LUPOSELLO, MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LUPOSELLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6858 OLD DOMINION DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3899
Mailing Address - Country:US
Mailing Address - Phone:703-356-8781
Mailing Address - Fax:703-442-4868
Practice Address - Street 1:6858 OLD DOMINION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3899
Practice Address - Country:US
Practice Address - Phone:703-356-8781
Practice Address - Fax:703-442-4868
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010078281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics