1265884423 NPI number — RESTON FAMILY DENTIST GROUP PLLC

Table of content: (NPI 1265884423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265884423 NPI number — RESTON FAMILY DENTIST GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTON FAMILY DENTIST GROUP 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:
6
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:
1265884423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12025 TOWN SQUARE ST
Provider Second Line Business Mailing Address:
UNIT 424
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20190-6026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-7945
Provider Business Mailing Address Fax Number:
571-313-0576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 ROBERT FULTON DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-5461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-423-7945
Provider Business Practice Location Address Fax Number:
571-313-0576
Provider Enumeration Date:
07/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MIAMEE
Authorized Official First Name:
ALI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
571-423-7945

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  0401412603 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X , with the licence number: 0401412603 , 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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