| Deep Roots Periodontics Pllc | |
|
11130 Fairfax Blvd Suite 100 Fairfax VA 22030-5035 | |
| (954) 536-1111 | |
| Not Available |
| Full Name | Deep Roots Periodontics Pllc |
|---|---|
| Speciality | Dentist - Periodontics |
| Location | 11130 Fairfax Blvd, Fairfax, Virginia |
| Authorized Official Name and Position | Taeheon Kang (PERIODONTIS) |
| Authorized Official Contact | 9545361111 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Deep Roots Periodontics Pllc 11130 Fairfax Blvd Suite 100 Fairfax VA 22030-5035 Ph: (954) 536-1111 | Deep Roots Periodontics Pllc 11130 Fairfax Blvd Suite 100 Fairfax VA 22030-5035 Ph: (954) 536-1111 |
| NPI Number | 1255695243 |
|---|---|
| Provider Enumeration Date | 06/25/2012 |
| Last Update Date | 06/25/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255695243 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0300X | Dentist - Periodontics | 0401-413327 (Virginia) | Primary |
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