Healthcare Provider Details

I. General information

NPI: 1043585995
Provider Name (Legal Business Name): HEIDI OSTRENG VATANKA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2012
Last Update Date: 03/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8505 ARLINGTON BLVD STE 370
FAIRFAX VA
22031-4621
US

IV. Provider business mailing address

2821 MOSBY ST
ALEXANDRIA VA
22305-1828
US

V. Phone/Fax

Practice location:
  • Phone: 703-849-1415
  • Fax:
Mailing address:
  • Phone: 571-527-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401413470
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: