Provider Demographics
NPI:1457450421
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:LOUDOUN COUNTY HEALTH DEPARTMENT-DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODFRIEND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-771-5829
Mailing Address - Street 1:PO BOX 7000- MSC #68
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20177-7000
Mailing Address - Country:US
Mailing Address - Phone:703-771-5830
Mailing Address - Fax:703-771-5550
Practice Address - Street 1:102 HERITAGE WAY NE
Practice Address - Street 2:1ST FLOOR SUITE #100
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-771-5830
Practice Address - Fax:703-771-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0013769Medicaid