Provider Demographics
NPI:1205933405
Name:LAKE RIDGE ENDODONTICS
Entity type:Organization
Organization Name:LAKE RIDGE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ENDODOTONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WYNKOOP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:703-494-8624
Mailing Address - Street 1:12510 LAKE RIDGE DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7501
Mailing Address - Country:US
Mailing Address - Phone:703-494-8624
Mailing Address - Fax:703-497-1258
Practice Address - Street 1:12510 C LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2335
Practice Address - Country:US
Practice Address - Phone:703-494-8624
Practice Address - Fax:703-497-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0410074641223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
872859OtherUNITED CONCORDIA
174982OtherBLUE CROSS BLUE SHIELD