Provider Demographics
NPI:1831225507
Name:FAIR OAKS SKIN CARE CENTER, LTD
Entity type:Organization
Organization Name:FAIR OAKS SKIN CARE CENTER, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DINTIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-648-2488
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-648-2488
Mailing Address - Fax:703-648-2489
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 403
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-648-2488
Practice Address - Fax:703-648-2489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty