| NPI | 1972940393 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TARA ANN FUGATE Practice Administrator 703-897-8983 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0401006414) |
| Enumeration Date | 2013-05-24 |
| Last Update Date | 2019-09-18 |