Provider Demographics
NPI:1740602291
Name:HERNDON DENTAL ARTS AT WOODLAND PARK, PLLC
Entity type:Organization
Organization Name:HERNDON DENTAL ARTS AT WOODLAND PARK, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-953-3307
Mailing Address - Street 1:12973 HIGHLAND CROSSING DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171
Mailing Address - Country:US
Mailing Address - Phone:703-953-3307
Mailing Address - Fax:703-953-3308
Practice Address - Street 1:12973 HIGHLAND CROSSING DRIVE
Practice Address - Street 2:STE B
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171
Practice Address - Country:US
Practice Address - Phone:703-953-3307
Practice Address - Fax:703-953-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014135201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty