Provider Demographics
NPI:1669843082
Name:ALEXANDRIA KIDS DENTISTRY, PC
Entity Type:Organization
Organization Name:ALEXANDRIA KIDS DENTISTRY, PC
Other - Org Name:ALEXANDRIA CHILDREN'S DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LANI
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:202-257-0727
Mailing Address - Street 1:2407 WASHINGTON OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-1454
Mailing Address - Country:US
Mailing Address - Phone:202-257-0727
Mailing Address - Fax:
Practice Address - Street 1:625 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-3019
Practice Address - Country:US
Practice Address - Phone:703-942-8404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007687648Medicaid