Provider Demographics
NPI:1053714766
Name:FAMILY ORTHODONTICS OF VIRGINIA LLC
Entity type:Organization
Organization Name:FAMILY ORTHODONTICS OF VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-389-1950
Mailing Address - Street 1:1350 SPRING ST NW STE 600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2870
Mailing Address - Country:US
Mailing Address - Phone:404-389-1950
Mailing Address - Fax:678-444-4152
Practice Address - Street 1:6225 BRANDON AVE STE 170
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2525
Practice Address - Country:US
Practice Address - Phone:404-389-1950
Practice Address - Fax:678-444-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014141641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty