Provider Demographics
NPI:1043407869
Name:BOUALLALI, SANAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANAE
Middle Name:
Last Name:BOUALLALI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LYNNHAVEN PKWY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1492
Mailing Address - Country:US
Mailing Address - Phone:757-410-5878
Mailing Address - Fax:757-410-5889
Practice Address - Street 1:2100 LYNNHAVEN PKWY
Practice Address - Street 2:SUITE #100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1492
Practice Address - Country:US
Practice Address - Phone:757-410-5878
Practice Address - Fax:757-410-5889
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA816276OtherUNITED CONCORDIA
VA019711OtherANTHEM