Provider Demographics
NPI:1194277715
Name:AWESOME KIDS DENTAL PLLC
Entity type:Organization
Organization Name:AWESOME KIDS DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TONTRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-261-2600
Mailing Address - Street 1:6468 TRADING SQ
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-2277
Mailing Address - Country:US
Mailing Address - Phone:571-261-2600
Mailing Address - Fax:571-261-2699
Practice Address - Street 1:6468 TRADING SQ
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-2277
Practice Address - Country:US
Practice Address - Phone:571-261-2600
Practice Address - Fax:571-261-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014115831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty