Provider Demographics
NPI:1538682034
Name:S&L DENTAL GROUP
Entity type:Organization
Organization Name:S&L DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-678-2875
Mailing Address - Street 1:5659 FAIRCLOTH CT
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1992
Mailing Address - Country:US
Mailing Address - Phone:617-678-2875
Mailing Address - Fax:
Practice Address - Street 1:5212 KINGS WOOD LN
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-5612
Practice Address - Country:US
Practice Address - Phone:617-678-2875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty