Provider Demographics
NPI:1114574654
Name:SEBASTIAN M BOURONCLE DDS-3 ALEXANDRIA PLLC
Entity Type:Organization
Organization Name:SEBASTIAN M BOURONCLE DDS-3 ALEXANDRIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL 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:703-933-8500
Mailing Address - Street 1:5252 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1404
Mailing Address - Country:US
Mailing Address - Phone:703-933-8500
Mailing Address - Fax:703-933-8506
Practice Address - Street 1:5252 DAWES AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1404
Practice Address - Country:US
Practice Address - Phone:703-933-8500
Practice Address - Fax:703-933-8506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty