Provider Demographics
NPI:1760673214
Name:MCLEAN ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:MCLEAN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORETICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MA
Authorized Official - Phone:703-893-8800
Mailing Address - Street 1:10440 NEW ASCOT DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-3421
Mailing Address - Country:US
Mailing Address - Phone:703-893-8800
Mailing Address - Fax:
Practice Address - Street 1:1515 CHAIN BRIDGE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4451
Practice Address - Country:US
Practice Address - Phone:703-893-8800
Practice Address - Fax:703-893-8845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3844302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization