Provider Demographics
NPI:1821166398
Name:PELKOFSKI, JOSEPH JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:PELKOFSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ROYAL STREET SE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-3014
Mailing Address - Country:US
Mailing Address - Phone:703-777-5200
Mailing Address - Fax:703-777-1629
Practice Address - Street 1:16 ROYAL STREET SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3014
Practice Address - Country:US
Practice Address - Phone:703-777-5200
Practice Address - Fax:703-777-1629
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA44691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA001236OtherANTHEM
197936231Medicare ID - Type Unspecified
VA001236OtherANTHEM