Provider Demographics
NPI:1982895470
Name:ULLRICH, JOHN JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:ULLRICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43063 PEACOCK MARKET PLZ
Mailing Address - Street 2:SUITE 125
Mailing Address - City:SOUTH RIDING
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4444
Mailing Address - Country:US
Mailing Address - Phone:703-327-0327
Mailing Address - Fax:
Practice Address - Street 1:43063 PEACOCK MARKET PLZ
Practice Address - Street 2:SUITE 125
Practice Address - City:SOUTH RIDING
Practice Address - State:VA
Practice Address - Zip Code:20152-4444
Practice Address - Country:US
Practice Address - Phone:703-327-0327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist