Provider Demographics
NPI:1154467249
Name:WOODSIDE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:WOODSIDE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOODSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-341-0014
Mailing Address - Street 1:400 HOLIDAY CT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-4349
Mailing Address - Country:US
Mailing Address - Phone:540-341-0014
Mailing Address - Fax:540-341-0303
Practice Address - Street 1:400 HOLIDAY CT
Practice Address - Street 2:SUITE 107
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-4349
Practice Address - Country:US
Practice Address - Phone:540-341-0014
Practice Address - Fax:540-341-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014110061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1777507OtherUNITED CONCORDIA
VA186781OtherANTHEM DENTAL
VA107966Medicaid