Provider Demographics
NPI:1346460300
Name:PATRON, ALFONSO LUIS (DDS)
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:LUIS
Last Name:PATRON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 MASSACHUSETTS AVE NW APT 719
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-5320
Mailing Address - Country:US
Mailing Address - Phone:267-265-2265
Mailing Address - Fax:
Practice Address - Street 1:505 HUNTMAR PARK DR STE 150
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5139
Practice Address - Country:US
Practice Address - Phone:703-736-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics