Provider Demographics
NPI:1245766484
Name:FAIRFAX DENTAL CENTER
Entity Type:Organization
Organization Name:FAIRFAX DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-273-1443
Mailing Address - Street 1:4000 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1047
Mailing Address - Country:US
Mailing Address - Phone:703-273-1443
Mailing Address - Fax:703-273-9186
Practice Address - Street 1:4000 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-1047
Practice Address - Country:US
Practice Address - Phone:703-273-1443
Practice Address - Fax:703-273-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty