Provider Demographics
NPI:1255817730
Name:FUSION DENTAL
Entity type:Organization
Organization Name:FUSION DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:BYERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:202-699-1027
Mailing Address - Street 1:1401 CHAIN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-6026
Mailing Address - Country:US
Mailing Address - Phone:703-821-1633
Mailing Address - Fax:
Practice Address - Street 1:1401 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-6026
Practice Address - Country:US
Practice Address - Phone:703-821-1633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER MARYLAND DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4014100401223P0221X
VA4010074781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty