Provider Demographics
NPI:1134504574
Name:HQ US ARMY DENTAL ACTIVITIES
Entity Type:Organization
Organization Name:HQ US ARMY DENTAL ACTIVITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-314-7944
Mailing Address - Street 1:577 STERNBERG AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1526
Mailing Address - Country:US
Mailing Address - Phone:757-314-7944
Mailing Address - Fax:757-314-7942
Practice Address - Street 1:577 STERNBURG AVENUE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23604-5311
Practice Address - Country:US
Practice Address - Phone:757-314-7944
Practice Address - Fax:757-314-7942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty