Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 0401008928 | VA |
NPI | 1013100601 |
---|---|
Provider Name | Dr. Stephane Tisseront |
First Address | Reston, VA 20190-4757 |
Second Address | Reston, VA 20190-4757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2007 |
Last Update Date | 29/08/2007 |