Provider Demographics
NPI:1649637828
Name:VIRGINIA CENTER FOR COSMETIC AND GENERAL DENTISTRY
Entity type:Organization
Organization Name:VIRGINIA CENTER FOR COSMETIC AND GENERAL DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:HETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:703-577-4317
Mailing Address - Street 1:1025 N FILLMORE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-6701
Mailing Address - Country:US
Mailing Address - Phone:703-243-7744
Mailing Address - Fax:703-243-7745
Practice Address - Street 1:1025 N FILLMORE ST
Practice Address - Street 2:SUITE A
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-6701
Practice Address - Country:US
Practice Address - Phone:703-243-7744
Practice Address - Fax:703-243-7745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014143671223G0001X
VA0401414929122300000X
VA0401415308122300000X
VA0401415279122300000X
VA04014138691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty