Provider Demographics
NPI:1295928208
Name:JACK C PHASS JR DDS INC
Entity type:Organization
Organization Name:JACK C PHASS JR DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHASS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-824-0055
Mailing Address - Street 1:5205 LEESBURG PIKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-3802
Mailing Address - Country:US
Mailing Address - Phone:703-824-0055
Mailing Address - Fax:703-998-9859
Practice Address - Street 1:5205 LEESBURG PIKE
Practice Address - Street 2:SUITE 101
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-3802
Practice Address - Country:US
Practice Address - Phone:703-824-0055
Practice Address - Fax:703-998-9859
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK C PHASS JR DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007124122300000X
VA04010086441223G0001X
VA04010066231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty