Healthcare Provider Details

I. General information

NPI: 1356696850
Provider Name (Legal Business Name): KINGSTOWNE PEDIATRIC DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025D MANCHESTER BLVD
ALEXANDRIA VA
22310-3227
US

IV. Provider business mailing address

3503 PENCE CT
ANNANDALE VA
22003-1426
US

V. Phone/Fax

Practice location:
  • Phone: 646-912-8726
  • Fax:
Mailing address:
  • Phone: 646-912-8726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateVA

VIII. Authorized Official

Name: MY TRAN
Title or Position: PARTNER
Credential: D.D.S
Phone: 646-912-8726