1295928208 NPI number — JACK C PHASS JR DDS INC

Table of content: (NPI 1295928208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295928208 NPI number — JACK C PHASS JR DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK C PHASS JR DDS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295928208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5205 LEESBURG PIKE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FALLS CHURCH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22041-3802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-824-0055
Provider Business Mailing Address Fax Number:
703-998-9859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5205 LEESBURG PIKE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22041-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-824-0055
Provider Business Practice Location Address Fax Number:
703-998-9859
Provider Enumeration Date:
08/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHASS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-824-0055

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0401007124 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 0401006623 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 0401008644 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)