Provider Demographics
NPI:1013059450
Name:VILLAVICENCIO, OLMEDO IVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:OLMEDO
Middle Name:IVAN
Last Name:VILLAVICENCIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 LITTLE RIVER TPKE STE 105
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2923
Mailing Address - Country:US
Mailing Address - Phone:703-354-2878
Mailing Address - Fax:703-354-2712
Practice Address - Street 1:7501 LITTLE RIVER TPKE STE 105
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2923
Practice Address - Country:US
Practice Address - Phone:703-354-2878
Practice Address - Fax:703-354-2712
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010077601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice