Basic Information
| Provider Information | |||||||||
| NPI: | 1588120224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADAM DENTAL CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16689 RIVER RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221914630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032219759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16689 RIVER RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221914630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032219759 | ||||||||
| FaxNumber: | 7032212782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2019 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | ELGARAWANY | ||||||||
| AuthorizedOfficialFirstName: | IBRAHIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7032219759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1124466347 | 05 | CT | MEDICAID |