Individual
SIU HSU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
10801 MAIN ST, STE 500 AND 600, FAIRFAX, VA 22030
(703) 352-2500
(703) 352-4500
Mailing address
10801 MAIN ST, STE 500 AND 600, FAIRFAX, VA 22030
(703) 352-2500
(703) 352-4500
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
0401007863
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14637
—
VA
Enumeration date
01/02/2007
Last updated
05/27/2008
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