Provider Demographics
NPI:1760828297
Name:PURCELLVILLE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PURCELLVILLE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOOSHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONAJEMY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-447-7627
Mailing Address - Street 1:17333 PICKWICK DR
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-6173
Mailing Address - Country:US
Mailing Address - Phone:540-441-7627
Mailing Address - Fax:
Practice Address - Street 1:17333 PICKWICK DR
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132
Practice Address - Country:US
Practice Address - Phone:540-441-7627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014101841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008220191Medicaid