Provider Demographics
NPI:1073057741
Name:SEBASTIAN M BOURONCLE DDS-2 STAFFORD PLLC
Entity Type:Organization
Organization Name:SEBASTIAN M BOURONCLE DDS-2 STAFFORD PLLC
Other - Org Name:NEW SMILES DENTAL STAFFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-720-1222
Mailing Address - Street 1:450 GARRISONVILLE RD
Mailing Address - Street 2:SUITE# 201
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1532
Mailing Address - Country:US
Mailing Address - Phone:540-720-1222
Mailing Address - Fax:
Practice Address - Street 1:450 GARRISONVILLE RD
Practice Address - Street 2:SUITE# 201
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1532
Practice Address - Country:US
Practice Address - Phone:540-720-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty