Provider Demographics
NPI:1639346182
Name:BOULEVARD DENTAL CLINIC
Entity Type:Organization
Organization Name:BOULEVARD DENTAL CLINIC
Other - Org Name:DR RICARDO M GAITAN DDS/PC
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:MOISES
Authorized Official - Last Name:GAITAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS/PC
Authorized Official - Phone:703-206-0466
Mailing Address - Street 1:8301 ARLINGTON BLVD
Mailing Address - Street 2:SUITE #403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2902
Mailing Address - Country:US
Mailing Address - Phone:703-206-0466
Mailing Address - Fax:703-206-0479
Practice Address - Street 1:8301 ARLINGTON BLVD
Practice Address - Street 2:SUITE #403
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2902
Practice Address - Country:US
Practice Address - Phone:703-206-0466
Practice Address - Fax:703-206-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008771261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherTAX ID