Provider Demographics
NPI:1437503075
Name:SATFFORD GENTLE DENTAL
Entity Type:Organization
Organization Name:SATFFORD GENTLE DENTAL
Other - Org Name:STAFFORD GENTLE TOUCH DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGALATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLLAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-944-2634
Mailing Address - Street 1:2777 JEFFERSON DAVIS HWY
Mailing Address - Street 2:UNIT 117
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8323
Mailing Address - Country:US
Mailing Address - Phone:703-933-2634
Mailing Address - Fax:
Practice Address - Street 1:2777 JEFFERSON DAVIS HWY
Practice Address - Street 2:UNIT 117
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8323
Practice Address - Country:US
Practice Address - Phone:703-933-2634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401411108OtherDENTIST LICENSE