Provider Demographics
NPI:1710485917
Name:CAPITAL DENTAL OF VIRGINIA, LLC
Entity Type:Organization
Organization Name:CAPITAL DENTAL OF VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CAMPOS VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-535-8126
Mailing Address - Street 1:3100 20TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2420
Mailing Address - Country:US
Mailing Address - Phone:202-526-6720
Mailing Address - Fax:202-269-0090
Practice Address - Street 1:3100 20TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2420
Practice Address - Country:US
Practice Address - Phone:202-526-6720
Practice Address - Fax:202-269-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty