Provider Demographics
NPI:1144406901
Name:CENTREVILLE CHILDREN'S DENTISTRY, PC
Entity Type:Organization
Organization Name:CENTREVILLE CHILDREN'S DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUKSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALAKSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-715-9555
Mailing Address - Street 1:14245M CENTREVILLE SQ
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2368
Mailing Address - Country:US
Mailing Address - Phone:703-715-9555
Mailing Address - Fax:
Practice Address - Street 1:14245M CENTREVILLE SQ
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2368
Practice Address - Country:US
Practice Address - Phone:703-715-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty