Provider Demographics
NPI:1225465131
Name:TREASURED SMILES PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:TREASURED SMILES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-293-0244
Mailing Address - Street 1:1509 DODONA TERRACE SUITE 105A
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:25405
Mailing Address - Country:US
Mailing Address - Phone:571-293-0244
Mailing Address - Fax:
Practice Address - Street 1:1509 DODONA TER STE 105A
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-4709
Practice Address - Country:US
Practice Address - Phone:571-293-0244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty