Provider Demographics
NPI:1992127989
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:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5141
Mailing Address - Street 1:11670 SUDLEY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2842
Mailing Address - Country:US
Mailing Address - Phone:571-359-6424
Mailing Address - Fax:571-359-6579
Practice Address - Street 1:11670 SUDLEY MANOR DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2842
Practice Address - Country:US
Practice Address - Phone:571-359-6424
Practice Address - Fax:571-359-6579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-10
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty