Provider Demographics
NPI:1942696513
Name:POTOMAC FALLS ORTHODONTICS
Entity Type:Organization
Organization Name:POTOMAC FALLS ORTHODONTICS
Other - Org Name:POTOMAC FALLS ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-638-2467
Mailing Address - Street 1:46950 JENNINGS FARM DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-8679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46950 JENNINGS FARM DR
Practice Address - Street 2:SUITE 160
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-8679
Practice Address - Country:US
Practice Address - Phone:703-430-2767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4014113501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty