Provider Demographics
NPI:1902207327
Name:GOOSE CREEK VILLAGE DENTAL
Entity Type:Organization
Organization Name:GOOSE CREEK VILLAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-723-4224
Mailing Address - Street 1:21001 SYCOLIN RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4073
Mailing Address - Country:US
Mailing Address - Phone:703-723-4224
Mailing Address - Fax:703-723-4220
Practice Address - Street 1:21001 SYCOLIN RD
Practice Address - Street 2:SUITE 240
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4073
Practice Address - Country:US
Practice Address - Phone:703-723-4224
Practice Address - Fax:703-723-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413573261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental