Provider Demographics
NPI:1275125809
Name:WALNUT DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:WALNUT DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-638-1420
Mailing Address - Street 1:3930 WALNUT ST STE 240
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4738
Mailing Address - Country:US
Mailing Address - Phone:703-638-1420
Mailing Address - Fax:703-638-1421
Practice Address - Street 1:3930 WALNUT ST STE 240
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4738
Practice Address - Country:US
Practice Address - Phone:703-638-1420
Practice Address - Fax:703-638-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty