MEDICARE: IDEAL DENTAL CARE , INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	0401412655	VA

General Provider Information

NPI Number	:	1780045849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL CARE , INC

Provider Business Mailing Address
First Line	:	8111 MIDLOTHIAN TPKE
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-5115
Country	:	US
Telephone Number	:	804-918-9667
Fax Number	:	804-918-9652

Provider Business Practice Location Address
First Line	:	8111 MIDLOTHIAN TPKE
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-5115
Country	:	US
Telephone Number	:	804-918-9667
Fax Number	:	804-918-9652

Authorized Official
Title or Position	:	DENTIST
Name	:	OMAR ABUHAJLEH
Credential	:	DDS
Telephone Number	:	781-254-2626

Provider Enumeration Date	:	03/16/2016
Last Update Date	:	03/16/2016

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Directions to “IDEAL DENTAL CARE , INC ” Practice Location

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