Provider Demographics
NPI:1659675122
Name:LAKE RIDGE ORTHODONTICS PC
Entity Type:Organization
Organization Name:LAKE RIDGE ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:F
Authorized Official - Last Name:SALEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:703-491-5166
Mailing Address - Street 1:12662 LAKE RIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7507
Mailing Address - Country:US
Mailing Address - Phone:703-491-5166
Mailing Address - Fax:703-494-4853
Practice Address - Street 1:12662 LAKE RIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7507
Practice Address - Country:US
Practice Address - Phone:703-491-5166
Practice Address - Fax:703-494-4853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014126691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty