Provider Demographics
NPI:1114357498
Name:PEARLY WHITES FAMILY DENTAL
Entity Type:Organization
Organization Name:PEARLY WHITES FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AGUSTINA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-992-7778
Mailing Address - Street 1:7227 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-3411
Mailing Address - Country:US
Mailing Address - Phone:703-992-7778
Mailing Address - Fax:571-565-2204
Practice Address - Street 1:7227 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-3411
Practice Address - Country:US
Practice Address - Phone:703-992-7778
Practice Address - Fax:571-565-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA040147137261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========Medicaid