Organization
NORTHERN VIRGINIA CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISS BRENDA LEE PICENTE (PRACTICE MANAGER)
(703) 449-8888
Entity
Organization
Contact information
Practice address
4211 FAIRFAX CORNER EAST AVE, SUITE # 235, FAIRFAX, VA 22030
(703) 449-8888
(703) 449-9888
Mailing address
4211 FAIRFAX CORNER EAST AVE, SUITE # 235, FAIRFAX, VA 22030
(703) 449-8888
(703) 449-9888
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
0401410440
VA
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
0438000163
VA
Other
Enumeration date
10/16/2006
Last updated
05/25/2011
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