Provider Demographics
NPI:1992103543
Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRED. SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:1020 ELDEN ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3843
Mailing Address - Country:US
Mailing Address - Phone:703-955-4221
Mailing Address - Fax:
Practice Address - Street 1:1020 ELDEN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3843
Practice Address - Country:US
Practice Address - Phone:703-955-4221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty