Provider Demographics
NPI:1720799109
Name:LEESBURG DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:LEESBURG DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-622-3300
Mailing Address - Street 1:8310 OLD COURTHOUSE RD STE A
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 CATOCTIN CIR NE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3100
Practice Address - Country:US
Practice Address - Phone:703-737-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental