Provider Demographics
NPI:1285914796
Name:CENTREVILLE DENTAL WELLNESS CENTER,PC.
Entity type:Organization
Organization Name:CENTREVILLE DENTAL WELLNESS CENTER,PC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAKAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-815-0775
Mailing Address - Street 1:14245F CENTREVILLE SQ
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2368
Mailing Address - Country:US
Mailing Address - Phone:703-815-0775
Mailing Address - Fax:703-222-7557
Practice Address - Street 1:14245F CENTREVILLE SQ
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2368
Practice Address - Country:US
Practice Address - Phone:703-815-0775
Practice Address - Fax:703-222-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010060271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty