Provider Demographics
NPI:1417245481
Name:MITNICK & HERBST, PC
Entity Type:Organization
Organization Name:MITNICK & HERBST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-444-3710
Mailing Address - Street 1:21475 RIDGETOP CIR
Mailing Address - Street 2:200
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6580
Mailing Address - Country:US
Mailing Address - Phone:703-444-3710
Mailing Address - Fax:703-444-8607
Practice Address - Street 1:21475 RIDGETOP CIR
Practice Address - Street 2:200
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6580
Practice Address - Country:US
Practice Address - Phone:703-444-3710
Practice Address - Fax:703-444-8607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA62321223G0001X
VA58761223P0221X
VA01841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0008375Medicaid
VA0012899Medicaid