Provider Demographics
NPI:1821155318
Name:RESTON DENTAL GROUP, PC
Entity Type:Organization
Organization Name:RESTON DENTAL GROUP, PC
Other - Org Name:FUSION DENTAL - ASHBURN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:20955 PROFESSIONAL PLZ STE 110
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3405
Mailing Address - Country:US
Mailing Address - Phone:703-723-0014
Mailing Address - Fax:703-723-0949
Practice Address - Street 1:20955 PROFESSIONAL PLZ STE 110
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3405
Practice Address - Country:US
Practice Address - Phone:703-723-0014
Practice Address - Fax:703-723-0949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty