Provider Demographics
NPI:1083978688
Name:BEL ALTON REGIONAL DENTAL CENTER
Entity Type:Organization
Organization Name:BEL ALTON REGIONAL DENTAL CENTER
Other - Org Name:BEL ALTON REGIONAL DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:JERONE
Authorized Official - Last Name:WINFREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-593-4299
Mailing Address - Street 1:9501 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:BEL ALTON
Mailing Address - State:MD
Mailing Address - Zip Code:20611-3146
Mailing Address - Country:US
Mailing Address - Phone:301-539-7904
Mailing Address - Fax:
Practice Address - Street 1:9501 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:BEL ALTON
Practice Address - State:MD
Practice Address - Zip Code:20611-3146
Practice Address - Country:US
Practice Address - Phone:301-539-7904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7804261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental