Provider Demographics
NPI:1205407467
Name:NOVA PERIO SPECIALISTS
Entity type:Organization
Organization Name:NOVA PERIO SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-444-4377
Mailing Address - Street 1:21165 WHITFIELD PL STE 107
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-7276
Mailing Address - Country:US
Mailing Address - Phone:703-444-4377
Mailing Address - Fax:703-444-7383
Practice Address - Street 1:21165 WHITFIELD PL STE 107
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-7276
Practice Address - Country:US
Practice Address - Phone:703-444-4377
Practice Address - Fax:703-444-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598038192OtherNPPES
1114232527OtherNPPES
1306299185OtherNPPES
1710362629OtherNPPES
1689223836OtherNPPES
1720123292OtherNPPES