Provider Demographics
NPI:1265273270
Name:LEE-THACKER, SOMANG (DMD)
Entity type:Individual
Prefix:
First Name:SOMANG
Middle Name:
Last Name:LEE-THACKER
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 FOUNTAINSIDE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6094
Mailing Address - Country:US
Mailing Address - Phone:502-802-1147
Mailing Address - Fax:
Practice Address - Street 1:4707 COLUMBIA PIKE UNIT C1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5923
Practice Address - Country:US
Practice Address - Phone:703-705-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418880122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist