Provider Demographics
NPI:1407484066
Name:HERNDON SMILE DESIGN PLLC
Entity Type:Organization
Organization Name:HERNDON SMILE DESIGN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-409-9202
Mailing Address - Street 1:504 ELDEN ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4741
Mailing Address - Country:US
Mailing Address - Phone:703-464-0000
Mailing Address - Fax:703-464-0066
Practice Address - Street 1:504 ELDEN ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4741
Practice Address - Country:US
Practice Address - Phone:703-464-0000
Practice Address - Fax:703-464-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty