Innovation Dental PLLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

0401410448 Issued in VA

Legal business name

INNOVATION DENTAL PLLC

Practice address

9940 Sowder Village Square
Manassas, VA 20109

Phone

(703) 330-3933

Fax

(703) 330-3517

NPI assigned

Jun 3, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Borarath Mak Yann, D.D.S.

Title

Owner

Phone

(703) 330-3933

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Wellington Dental Associates Former legal business name

Tax ID family

Innovation Dental PLLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Innovation Dental PLLC

  • General Practice Dentistry
  • Bristow, VA
  • NPI 1295325991
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1243987200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1243987200000",
    "number": "1225264302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9940 SOWDER VILLAGE SQUARE",
            "city": "MANASSAS",
            "state": "VA",
            "postal_code": "20109",
            "telephone_number": "703-330-3933",
            "fax_number": "703-330-3517"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9940 SOWDER VILLAGE SQUARE",
            "city": "MANASSAS",
            "state": "VA",
            "postal_code": "20109",
            "telephone_number": "703-330-3933",
            "fax_number": "703-330-3517"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNOVATION DENTAL PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-03",
        "last_updated": "2009-06-03",
        "status": "A",
        "authorized_official_last_name": "YANN",
        "authorized_official_first_name": "BORARATH",
        "authorized_official_middle_name": "MAK",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "703-330-3933",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "VA",
            "license": "0401410448",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1083887194",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wellington Dental Associates",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• General Practice Dentistry in Manassas, VA
• Providers in Manassas, VA by specialty
• General Practice Dentistry in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.