1285807370 NPI number — MY BRACES DOCTOR, PC

Table of content: STEVEN J. COLONNA MD (NPI 1407112287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285807370 NPI number — MY BRACES DOCTOR, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY BRACES DOCTOR, PC
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:
1285807370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10721 MAIN ST
Provider Second Line Business Mailing Address:
#300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-6914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-591-6686
Provider Business Mailing Address Fax Number:
703-277-7674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10721 MAIN ST
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-6914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-591-6686
Provider Business Practice Location Address Fax Number:
703-277-7674
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SINA
Authorized Official First Name:
NAHID
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
703-966-7959

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LOCATION ID: 010495 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PROVIDER NO: 0012081 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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