Provider Demographics
NPI:1144586298
Name:DIAMOND DENTAL CARE
Entity Type:Organization
Organization Name:DIAMOND DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-773-1212
Mailing Address - Street 1:13948 LEE JACKSON MEMORIAL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151
Mailing Address - Country:US
Mailing Address - Phone:703-773-1212
Mailing Address - Fax:703-773-1214
Practice Address - Street 1:13948 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3202
Practice Address - Country:US
Practice Address - Phone:703-773-1212
Practice Address - Fax:703-773-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008860122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010378214Medicaid