Provider Demographics
NPI:1093466583
Name:RIVERSIDE DENTAL, PLLC
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHUTONG
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-740-8978
Mailing Address - Street 1:6161 FOXCROFT RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-1103
Mailing Address - Country:US
Mailing Address - Phone:828-719-5723
Mailing Address - Fax:
Practice Address - Street 1:3400 S CLARK ST STE 105
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-4050
Practice Address - Country:US
Practice Address - Phone:703-740-8978
Practice Address - Fax:571-464-6588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty