1457720302 NPI number — TJB OF DULLES, LLC

Table of content: (NPI 1457720302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457720302 NPI number — TJB OF DULLES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TJB OF DULLES, LLC
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:
LOUDOUN DENTAL ASSOCIATES & SMILEZ PEDIATRIC DENTAL GROUP
Provider Other Organization Name Type Code:
3
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:
1457720302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24565 DULLES LANDING DR
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
DULLES
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20166-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-542-7300
Provider Business Mailing Address Fax Number:
703-754-1694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24565 DULLES LANDING DR
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
DULLES
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20166-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-468-0188
Provider Business Practice Location Address Fax Number:
703-754-1694
Provider Enumeration Date:
09/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
KERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL DIRECTOR
Authorized Official Telephone Number:
540-494-8776

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  0401007652 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QD0000X , with the licence number: 0401410720 , 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)





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