Provider Demographics
NPI:1639259773
Name:NORTHERN VIRGINIA CENTER
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-449-8888
Mailing Address - Street 1:4211 FAIRFAX CORNER EAST AVE
Mailing Address - Street 2:SUITE # 235
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-449-8888
Mailing Address - Fax:703-449-9888
Practice Address - Street 1:4211 FAIRFAX CORNER EAST AVE
Practice Address - Street 2:SUITE # 235
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-449-8888
Practice Address - Fax:703-449-9888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410440122300000X
VA04380001631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty