Provider Demographics
NPI:1710390042
Name:DENTAL ONE ASSOCIATES (OLD DOMINION) PLLC
Entity Type:Organization
Organization Name:DENTAL ONE ASSOCIATES (OLD DOMINION) PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-1611
Mailing Address - Street 1:9942 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9942 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3901
Practice Address - Country:US
Practice Address - Phone:703-273-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty