Provider Demographics
NPI:1457720302
Name:TJB OF DULLES, LLC
Entity Type:Organization
Organization Name:TJB OF DULLES, LLC
Other - Org Name:LOUDOUN DENTAL ASSOCIATES & SMILEZ PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-494-8776
Mailing Address - Street 1:24565 DULLES LANDING DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:DULLES
Mailing Address - State:VA
Mailing Address - Zip Code:20166-2612
Mailing Address - Country:US
Mailing Address - Phone:703-542-7300
Mailing Address - Fax:703-754-1694
Practice Address - Street 1:24565 DULLES LANDING DR
Practice Address - Street 2:SUITE 190
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2612
Practice Address - Country:US
Practice Address - Phone:703-468-0188
Practice Address - Fax:703-754-1694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007652261QD0000X
VA0401410720261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental