1265190417 NPI number — SOUTH FORK DENTISTRY PLLC

Table of content: (NPI 1265190417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265190417 NPI number — SOUTH FORK DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH FORK DENTISTRY PLLC
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:
1265190417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19783 WILLOWDALE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-5209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-297-6793
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
723 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PURCELLVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-335-7480
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MAHAL
Authorized Official First Name:
SIMREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
571-335-7480

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1922408160 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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