Provider Demographics
NPI:1659038883
Name:PEDIATRIC SMILES OF FAIRFAX, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC SMILES OF FAIRFAX, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAZMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-472-5358
Mailing Address - Street 1:12705 THERESA DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3561
Mailing Address - Country:US
Mailing Address - Phone:908-472-5358
Mailing Address - Fax:
Practice Address - Street 1:13135 LEE JACKSON HWY STE 110
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1909
Practice Address - Country:US
Practice Address - Phone:908-472-5358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental