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14016 Sullyfield Cir Ste B Chantilly VA 20151-4010 | |
| (703) 815-0699 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 14016 Sullyfield Cir Ste B, Chantilly, Virginia |
| Authorized Official Name and Position | Philip I. Koh (OWNER) |
| Authorized Official Contact | 7038150699 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
14016 Sullyfield Cir Ste B Chantilly VA 20151-4010 Ph: (703) 815-0699 | 14016 Sullyfield Cir Ste B Chantilly VA 20151-4010 Ph: (703) 815-0699 |
| NPI Number | 1992212310 |
|---|---|
| Provider Enumeration Date | 01/08/2018 |
| Last Update Date | 02/05/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1992212310 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 0401411961 (Virginia) | Primary |
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