Provider Demographics
NPI:1952907842
Name:M MINNIEVILLE DENTAL CARE PLLC
Entity type:Organization
Organization Name:M MINNIEVILLE DENTAL CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS OSORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-589-7040
Mailing Address - Street 1:4222 FORTUNA CENTER PLZ # 637
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14389 HEREFORD RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2107
Practice Address - Country:US
Practice Address - Phone:703-878-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOMENTUM DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-07
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty