Provider Demographics
NPI:1700217221
Name:EA DENTAL
Entity Type:Organization
Organization Name:EA DENTAL
Other - Org Name:RESTON DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-691-2938
Mailing Address - Street 1:25870 RAWLEY SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-5767
Mailing Address - Country:US
Mailing Address - Phone:703-598-8875
Mailing Address - Fax:
Practice Address - Street 1:11345 SUNSET HILLS RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5205
Practice Address - Country:US
Practice Address - Phone:703-689-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty