Provider Demographics
NPI:1659724185
Name:PEDIATRIC DENTISTRY OF KING GEORGE
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF KING GEORGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:540-625-2007
Mailing Address - Street 1:1300 THORNTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4654
Mailing Address - Country:US
Mailing Address - Phone:540-371-3222
Mailing Address - Fax:
Practice Address - Street 1:10246 KINGS HWY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-3429
Practice Address - Country:US
Practice Address - Phone:540-625-2007
Practice Address - Fax:540-371-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014132601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty