Provider Demographics
NPI:1679248926
Name:DENTRUST DENTAL VIRGINIA, P.C.
Entity Type:Organization
Organization Name:DENTRUST DENTAL VIRGINIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-927-5000
Mailing Address - Street 1:1221 VINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-4829
Mailing Address - Country:US
Mailing Address - Phone:813-451-4503
Mailing Address - Fax:
Practice Address - Street 1:8651 JOHN J KINGMAN RD BLDG 2321
Practice Address - Street 2:
Practice Address - City:FT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-6200
Practice Address - Country:US
Practice Address - Phone:267-927-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTRUST DENTAL VIRGINIA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401412009OtherDR.CAPLINS VA LIC