Provider Demographics
NPI:1356539100
Name:LAKE MANASSA DENTAL CENTER
Entity type:Organization
Organization Name:LAKE MANASSA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LONG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-641-8825
Mailing Address - Street 1:6911 STANWICK SQ
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-4424
Mailing Address - Country:US
Mailing Address - Phone:646-641-8825
Mailing Address - Fax:
Practice Address - Street 1:7915 LAKE MANASSAS DR
Practice Address - Street 2:STE 115
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:646-641-8825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty