Provider Demographics
NPI:1609829373
Name:MITNICK, HOWARD M JR (DDS)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:M
Last Name:MITNICK
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21475 RIDGETOP CIRCLE
Mailing Address - Street 2:#200
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166
Mailing Address - Country:US
Mailing Address - Phone:703-444-3710
Mailing Address - Fax:703-444-8607
Practice Address - Street 1:21475 RIDGETOP CIRCLE
Practice Address - Street 2:#200
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166
Practice Address - Country:US
Practice Address - Phone:703-444-3710
Practice Address - Fax:703-444-8607
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6232122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice