| NPI | 1972717569 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEFFREY DAVID WAGMAN Owner 703-379-6187 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: VA 0401008271) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2020-08-22 |