Provider Demographics
NPI:1700469103
Name:DEDICATED DENTAL PLLC
Entity Type:Organization
Organization Name:DEDICATED DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-901-4700
Mailing Address - Street 1:11 HOPE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7287
Mailing Address - Country:US
Mailing Address - Phone:540-318-8691
Mailing Address - Fax:
Practice Address - Street 1:11 HOPE RD STE 201
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7287
Practice Address - Country:US
Practice Address - Phone:540-899-1777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401413995OtherDENTAL LICENSE NUMBER
VA0401416501OtherDENTAL LICENSE NUMBER