Provider Demographics
NPI:1912070319
Name:ORANGE COUNTY DENTAL CLINIC
Entity Type:Organization
Organization Name:ORANGE COUNTY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-347-6400
Mailing Address - Street 1:450 NORTH MADISON ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:VA
Mailing Address - Zip Code:22960
Mailing Address - Country:US
Mailing Address - Phone:540-672-1291
Mailing Address - Fax:540-672-1766
Practice Address - Street 1:450 NORTH MADISON ROAD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:VA
Practice Address - Zip Code:22960
Practice Address - Country:US
Practice Address - Phone:540-672-1291
Practice Address - Fax:540-672-1766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975804Medicaid
0401006380OtherLIC #