Healthcare Provider Details

I. General information

NPI: 1669843082
Provider Name (Legal Business Name): ALEXANDRIA KIDS DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E MONROE AVE
ALEXANDRIA VA
22301-3019
US

IV. Provider business mailing address

2407 WASHINGTON OVERLOOK DR
FORT WASHINGTON MD
20744-1454
US

V. Phone/Fax

Practice location:
  • Phone: 703-942-8404
  • Fax:
Mailing address:
  • Phone: 202-257-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0401411222
License Number StateVA

VIII. Authorized Official

Name: DR. ANGELA LANI AUSTIN
Title or Position: PEDIATRIC DENTIST/OWNER
Credential: DMD
Phone: 202-257-0727