Healthcare Provider Details

I. General information

NPI: 1134223746
Provider Name (Legal Business Name): ALEXANDRIA HEALTH DEPARTMENT DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4480 KING ST
ALEXANDRIA VA
22302-1300
US

IV. Provider business mailing address

4480 KING ST
ALEXANDRIA VA
22302-1300
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL L. WIENER
Title or Position: ADMINISTRATOR
Credential:
Phone: 703-838-4400