Provider Demographics
NPI:1427128669
Name:RESTON DENTAL GROUP, PC
Entity type:Organization
Organization Name:RESTON DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-860-3200
Mailing Address - Street 1:11107 SUNSET HILLS RD STE 111
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5481
Mailing Address - Country:US
Mailing Address - Phone:703-860-3200
Mailing Address - Fax:703-391-8228
Practice Address - Street 1:11107 SUNSET HILLS RD STE 111
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5481
Practice Address - Country:US
Practice Address - Phone:703-860-3200
Practice Address - Fax:703-391-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental