Provider Demographics
NPI:1518465939
Name:ALEXANDRIA OLD TOWN DENTAL PLLC
Entity Type:Organization
Organization Name:ALEXANDRIA OLD TOWN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:SEYMOUR
Authorized Official - Last Name:LONGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-549-1331
Mailing Address - Street 1:1421 PRINCE ST STE 140
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2771
Mailing Address - Country:US
Mailing Address - Phone:703-549-1331
Mailing Address - Fax:703-549-0480
Practice Address - Street 1:1421 PRINCE ST STE 140
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2771
Practice Address - Country:US
Practice Address - Phone:703-549-1331
Practice Address - Fax:703-549-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541192045OtherGENERAL DENTIST