Provider Demographics
NPI:1457664039
Name:FREDERICKSBURG DENTAL PROFESSIONALS,PLLC
Entity Type:Organization
Organization Name:FREDERICKSBURG DENTAL PROFESSIONALS,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:QURESHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-412-9527
Mailing Address - Street 1:4510 PLANK RD
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-0138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4510 PLANK RD
Practice Address - Street 2:SUITE # 100
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0138
Practice Address - Country:US
Practice Address - Phone:540-412-9527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014119761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11597Medicaid