Provider Demographics
NPI:1679793079
Name:FAIRFAX, CERINA WANZER (DDS)
Entity type:Individual
Prefix:DR
First Name:CERINA
Middle Name:WANZER
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 LEE HWY # B
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2303
Mailing Address - Country:US
Mailing Address - Phone:703-273-1033
Mailing Address - Fax:
Practice Address - Street 1:9500 LEE HWY # B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2303
Practice Address - Country:US
Practice Address - Phone:703-273-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice