Basic Information
| Provider Information | |||||||||
| NPI: | 1447433578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEAM DENTAL AT RIVER OAKS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16689 RIVER RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221914630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032219759 | ||||||||
| FaxNumber: | 7032212782 | ||||||||
| Practice Location | |||||||||
| Address1: | 16689 RIVER RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221914630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032219759 | ||||||||
| FaxNumber: | 7032212782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ENON | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7032219759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 8593 | VA | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.