1073990594 NPI number — PRESTIGE DENTAL SPECIALISTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073990594 NPI number — PRESTIGE DENTAL SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESTIGE DENTAL SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073990594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7630 LITTLE RIVER TPKE
Provider Second Line Business Mailing Address:
115
Provider Business Mailing Address City Name:
ANNANDALE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22003-2610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-256-2556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7630 LITTLE RIVER TPKE
Provider Second Line Business Practice Location Address:
115
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-256-2556
Provider Business Practice Location Address Fax Number:
703-256-7722
Provider Enumeration Date:
05/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PHISUTHIKUL
Authorized Official First Name:
NORACHAI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-256-2556

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0401412751 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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