Provider Demographics
NPI:1497979504
Name:FAIRFAX ORTHODONTIC ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:FAIRFAX ORTHODONTIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCABE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-719-5828
Mailing Address - Street 1:12011 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3310
Mailing Address - Country:US
Mailing Address - Phone:703-691-9061
Mailing Address - Fax:
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3310
Practice Address - Country:US
Practice Address - Phone:703-691-9061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007980305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization