1356696850 NPI number — KINGSTOWNE PEDIATRIC DENTISTRY, PLLC

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 1356696850 NPI number — KINGSTOWNE PEDIATRIC DENTISTRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSTOWNE PEDIATRIC DENTISTRY, PLLC
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:
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:
1356696850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3503 PENCE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNANDALE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22003-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-912-8726
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7025D MANCHESTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22310-3227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-912-8726
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TRAN
Authorized Official First Name:
MY
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
646-912-8726

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , 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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