Provider Demographics
NPI:1003652207
Name:ORAL WELLNESS CENTER OF VIRGINIA
Entity type:Organization
Organization Name:ORAL WELLNESS CENTER OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-965-4188
Mailing Address - Street 1:12001 MARKET ST APT 201
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-6213
Mailing Address - Country:US
Mailing Address - Phone:703-965-4188
Mailing Address - Fax:
Practice Address - Street 1:300 HICKMAN RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3554
Practice Address - Country:US
Practice Address - Phone:434-296-3941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental