Provider Demographics
NPI:1770707572
Name:ALEXANDRIA ORAL SURGERY, PC
Entity type:Organization
Organization Name:ALEXANDRIA ORAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-370-3012
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-370-3012
Mailing Address - Fax:703-370-6005
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-370-3012
Practice Address - Fax:703-370-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA053901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT30928Medicare UPIN
VA00B992G01Medicare ID - Type Unspecified