Provider Demographics
NPI:1205206257
Name:ALEXANDRIA CHILDREN'S DENTISTRY, P.C.
Entity Type:Organization
Organization Name:ALEXANDRIA CHILDREN'S DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LANI
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-942-8404
Mailing Address - Street 1:6303 LITTLE RIVER TURNPIKE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312
Mailing Address - Country:US
Mailing Address - Phone:703-942-8404
Mailing Address - Fax:703-890-8726
Practice Address - Street 1:6303 LITTLE RIVER TURNPIKE
Practice Address - Street 2:SUITE 160
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312
Practice Address - Country:US
Practice Address - Phone:703-942-8404
Practice Address - Fax:703-890-8726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-03
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
VA0401411222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007687648Medicaid