Healthcare Provider Details

I. General information

NPI: 1609291533
Provider Name (Legal Business Name): PARKER-GRAY PEDIATRIC DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2014
Last Update Date: 03/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 N FAYETTE ST
ALEXANDRIA VA
22314-2433
US

IV. Provider business mailing address

224 N FAYETTE ST
ALEXANDRIA VA
22314-2433
US

V. Phone/Fax

Practice location:
  • Phone: 703-519-7275
  • Fax: 703-519-7276
Mailing address:
  • Phone: 703-519-7275
  • Fax: 703-519-7276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401413943
License Number StateVA

VIII. Authorized Official

Name: DR. KESHA STEPHENSON
Title or Position: DDS/OWNER
Credential:
Phone: 301-651-9592