Provider Demographics
NPI:1750669883
Name:DYNAMIC DENTAL PC
Entity type:Organization
Organization Name:DYNAMIC DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:FARIDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:KHATTAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-531-0010
Mailing Address - Street 1:159 HILLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-2913
Mailing Address - Country:US
Mailing Address - Phone:703-531-0010
Mailing Address - Fax:703-531-1330
Practice Address - Street 1:159 HILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-2913
Practice Address - Country:US
Practice Address - Phone:703-531-0010
Practice Address - Fax:703-531-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014123861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1841430873OtherNPI