Provider Demographics
NPI:1205048972
Name:DENTAL ONE ASSOCIATES (WOODSON SQUARE), LTD
Entity type:Organization
Organization Name:DENTAL ONE ASSOCIATES (WOODSON SQUARE), LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:9661 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3757
Mailing Address - Country:US
Mailing Address - Phone:703-425-3737
Mailing Address - Fax:703-425-3762
Practice Address - Street 1:9661 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3757
Practice Address - Country:US
Practice Address - Phone:703-425-3737
Practice Address - Fax:703-425-3762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty