Provider Demographics
NPI:1013469980
Name:WOODLAKE DENTAL CENTER
Entity Type:Organization
Organization Name:WOODLAKE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-739-9190
Mailing Address - Street 1:6508 WOODLAKE VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2200
Mailing Address - Country:US
Mailing Address - Phone:804-739-9190
Mailing Address - Fax:804-739-9543
Practice Address - Street 1:6508 WOODLAKE VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2200
Practice Address - Country:US
Practice Address - Phone:804-739-9190
Practice Address - Fax:804-739-9543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty