Provider Demographics
NPI:1164402384
Name:DEMETRIUS, EDA PATRICIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDA
Middle Name:PATRICIA
Last Name:DEMETRIUS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:EDA
Other - Middle Name:PATRICIA
Other - Last Name:JACKSON-DEMETRIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6573 FOREST DEW CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2184
Mailing Address - Country:US
Mailing Address - Phone:571-217-0552
Mailing Address - Fax:
Practice Address - Street 1:6573 FOREST DEW CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2184
Practice Address - Country:US
Practice Address - Phone:571-217-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BD8160284OtherFEDERAL DEA