Provider Demographics
NPI:1588303556
Name:LOUDOUN ENDODONTICS, PLLC
Entity type:Organization
Organization Name:LOUDOUN ENDODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:DETAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:703-368-8120
Mailing Address - Street 1:14426 BECKETT GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2140
Mailing Address - Country:US
Mailing Address - Phone:703-851-6885
Mailing Address - Fax:
Practice Address - Street 1:2 CARDINAL PARK DR SE STE 106A
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-4448
Practice Address - Country:US
Practice Address - Phone:703-779-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-30
Last Update Date:2022-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty