Provider Demographics
NPI:1821434127
Name:POTOMAC MILLS FAMILY DENTAL
Entity Type:Organization
Organization Name:POTOMAC MILLS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-658-3000
Mailing Address - Street 1:14338 GIDEON DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4640
Mailing Address - Country:US
Mailing Address - Phone:703-348-8070
Mailing Address - Fax:
Practice Address - Street 1:14338 GIDEON DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4640
Practice Address - Country:US
Practice Address - Phone:703-348-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANDMARK FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014121171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty