Healthcare Provider Details

I. General information

NPI: 1104928894
Provider Name (Legal Business Name): RAYMOND C HASTON JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14393 HEREFORD RD
DALE CITY VA
22193-2107
US

IV. Provider business mailing address

14393 HEREFORD RD
DALE CITY VA
22193-2107
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-8400
  • Fax: 703-690-2050
Mailing address:
  • Phone: 703-670-8400
  • Fax: 703-690-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number05372
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: