Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 5558 | VA |
NPI | 1154486322 |
---|---|
Provider Name | Leo Sushner |
First Address | Falls Church, VA 22041-3257 |
Second Address | Falls Church, VA 22041-3257 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2006 |
Last Update Date | 08/07/2007 |