Provider Demographics
NPI:1902360068
Name:FAIRFAX ADVANCED DENTISTRY, P.C.
Entity Type:Organization
Organization Name:FAIRFAX ADVANCED DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:OSINOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-861-8777
Mailing Address - Street 1:3930 PENDER DR STE 150
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0986
Mailing Address - Country:US
Mailing Address - Phone:703-650-9299
Mailing Address - Fax:
Practice Address - Street 1:3930 PENDER DR STE 150
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0986
Practice Address - Country:US
Practice Address - Phone:703-650-9299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty