Provider Demographics
NPI:1801242466
Name:DENTAL CENTER @ LAKE RIDGE
Entity type:Organization
Organization Name:DENTAL CENTER @ LAKE RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THAO
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-499-8888
Mailing Address - Street 1:12764 DARBY BROOK CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2486
Mailing Address - Country:US
Mailing Address - Phone:703-499-8888
Mailing Address - Fax:
Practice Address - Street 1:12764 DARBY BROOK CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2486
Practice Address - Country:US
Practice Address - Phone:703-499-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410245261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center