Provider Demographics
NPI:1295325991
Name:INNOVATION DENTAL PLLC
Entity type:Organization
Organization Name:INNOVATION DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORARATH
Authorized Official - Middle Name:M
Authorized Official - Last Name:YANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-330-3933
Mailing Address - Street 1:9070 DEVLIN RD
Mailing Address - Street 2:STE 110
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136
Mailing Address - Country:US
Mailing Address - Phone:703-330-3933
Mailing Address - Fax:571-248-2043
Practice Address - Street 1:9070 DEVLIN RD
Practice Address - Street 2:STE 110
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136
Practice Address - Country:US
Practice Address - Phone:703-330-3933
Practice Address - Fax:571-248-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty