Provider Demographics
NPI:1710477815
Name:PD DENTAL PLLC
Entity Type:Organization
Organization Name:PD DENTAL PLLC
Other - Org Name:FAMILY DENTAL OF FAIRFAX CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DARY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:571-426-4579
Mailing Address - Street 1:12791 FAIR BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3850
Mailing Address - Country:US
Mailing Address - Phone:571-426-4579
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6913
Practice Address - Country:US
Practice Address - Phone:703-865-8829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414585261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental