Provider Demographics
NPI:1861193997
Name:WOODBRIDGE DENTAL GROUP PLLC
Entity type:Organization
Organization Name:WOODBRIDGE DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-622-3300
Mailing Address - Street 1:8310 OLD COURTHOUSE RD STE A
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14416 RICHMOND HWY STE 16
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-2890
Practice Address - Country:US
Practice Address - Phone:703-492-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental