Provider Demographics
NPI:1518749423
Name:BLOSSOM SMILE OF WOODBRIDGE PLLC
Entity Type:Organization
Organization Name:BLOSSOM SMILE OF WOODBRIDGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSSEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALHASAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:916-622-2098
Mailing Address - Street 1:6800 FLEETWOOD RD APT 1001
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3610
Mailing Address - Country:US
Mailing Address - Phone:916-622-2098
Mailing Address - Fax:
Practice Address - Street 1:12618 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2335
Practice Address - Country:US
Practice Address - Phone:916-622-2098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty