Provider Demographics
NPI:1639509102
Name:OPTIMUM DENTAL
Entity Type:Organization
Organization Name:OPTIMUM DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-876-4700
Mailing Address - Street 1:7389 LEE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1737
Mailing Address - Country:US
Mailing Address - Phone:703-876-4700
Mailing Address - Fax:703-876-4705
Practice Address - Street 1:7389 LEE HWY STE 101
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1737
Practice Address - Country:US
Practice Address - Phone:703-876-4700
Practice Address - Fax:703-876-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04041411907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty