Provider Demographics
NPI:1992011233
Name:DULLES ORAL SURGICAL CENTER
Entity Type:Organization
Organization Name:DULLES ORAL SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:AUDUBORN
Authorized Official - Last Name:LONGWE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-327-0955
Mailing Address - Street 1:24805 PINEBROOK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4127
Mailing Address - Country:US
Mailing Address - Phone:703-327-0955
Mailing Address - Fax:703-327-0956
Practice Address - Street 1:24805 PINEBROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-4127
Practice Address - Country:US
Practice Address - Phone:703-327-0955
Practice Address - Fax:703-327-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0438000264261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center