Provider Demographics
NPI:1912399395
Name:DYNAMIC FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:DYNAMIC FOOT AND ANKLE CENTER
Other - Org Name:DYNAMIC FOOT AND ANKLE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:DANNIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VONDERLINDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-418-8670
Mailing Address - Street 1:9010 LORTON STATION BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4792
Mailing Address - Country:US
Mailing Address - Phone:571-418-8670
Mailing Address - Fax:571-418-8671
Practice Address - Street 1:9010 LORTON STATION BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4792
Practice Address - Country:US
Practice Address - Phone:571-418-8670
Practice Address - Fax:571-418-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301037213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7404180001Medicare NSC