Provider Demographics
NPI:1124414537
Name:ANGEL HEART & SOUL DENTISTRY
Entity Type:Organization
Organization Name:ANGEL HEART & SOUL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEMARI
Authorized Official - Middle Name:DE LEON
Authorized Official - Last Name:IMAO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:585-354-1168
Mailing Address - Street 1:2942 PATRICK HENRY DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-2904
Mailing Address - Country:US
Mailing Address - Phone:703-533-8808
Mailing Address - Fax:703-533-8420
Practice Address - Street 1:2942 PATRICK HENRY DR
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2904
Practice Address - Country:US
Practice Address - Phone:703-533-8808
Practice Address - Fax:703-533-8420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014122841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty