Provider Demographics
NPI:1053324434
Name:RUBIN, MICHAEL FORMAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FORMAN
Last Name:RUBIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 COLUMBIA PIKE STE 100
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-4431
Mailing Address - Country:US
Mailing Address - Phone:703-521-8843
Mailing Address - Fax:703-521-1716
Practice Address - Street 1:2121 COLUMBIA PIKE STE 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-4431
Practice Address - Country:US
Practice Address - Phone:703-521-8843
Practice Address - Fax:703-521-1716
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice