Provider Demographics
NPI:1710907134
Name:FAIRFAX ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:FAIRFAX ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPRADLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-385-5777
Mailing Address - Street 1:10530 ROSEHAVEN ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2840
Mailing Address - Country:US
Mailing Address - Phone:703-385-5777
Mailing Address - Fax:703-591-5386
Practice Address - Street 1:10530 ROSEHAVEN ST
Practice Address - Street 2:SUITE 111
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2840
Practice Address - Country:US
Practice Address - Phone:703-385-5777
Practice Address - Fax:703-591-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA597426Medicare UPIN