Provider Demographics
NPI:1710496294
Name:FAIRFAX DENTISTRY, PLLC
Entity Type:Organization
Organization Name:FAIRFAX DENTISTRY, PLLC
Other - Org Name:SAMUEL S. HAM, DDS, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:SAEHO
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-691-2221
Mailing Address - Street 1:11351 RANDOM HILLS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6081
Mailing Address - Country:US
Mailing Address - Phone:703-691-2221
Mailing Address - Fax:703-691-3215
Practice Address - Street 1:11351 RANDOM HILLS RD STE 102
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6081
Practice Address - Country:US
Practice Address - Phone:703-691-2221
Practice Address - Fax:703-691-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty