Provider Demographics
NPI:1740604693
Name:ALEXANDRIA PEDIATRIC DENTISTRY, PLC
Entity Type:Organization
Organization Name:ALEXANDRIA PEDIATRIC DENTISTRY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WONG
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:571-257-5744
Mailing Address - Street 1:3223 DUKE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4586
Mailing Address - Country:US
Mailing Address - Phone:571-257-5744
Mailing Address - Fax:571-257-5759
Practice Address - Street 1:3223 DUKE ST
Practice Address - Street 2:SUITE A
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4586
Practice Address - Country:US
Practice Address - Phone:571-257-5744
Practice Address - Fax:571-257-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty