MEDICARE: DENTAQUEST VIRGINIA, 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	122300000X	Dentist

General Provider Information

NPI Number	:	1801138789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAQUEST VIRGINIA, INC.

Provider Business Mailing Address
First Line	:	465 MEDFORD ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02129-1426
Country	:	US
Telephone Number	:	617-886-1818
Fax Number	:

Provider Business Practice Location Address
First Line	:	4061 POWDER MILL RD
Second Line	:	SUITE 325
City	:	CALVERTON
State	:	MD
Zip	:	20705-3149
Country	:	US
Telephone Number	:	617-886-1818
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STEVEN J. POLLOCK
Credential	:
Telephone Number	:	617-886-1568

Provider Enumeration Date	:	03/19/2013
Last Update Date	:	03/19/2013

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