Healthcare Provider Details

I. General information

NPI: 1760386122
Provider Name (Legal Business Name): LAKE PLAZA DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36101 GOODWIN DRIVE
LOCUST GROVE VA
22508
US

IV. Provider business mailing address

36101 GOODWIN DRIVE
LOCUST GROVE VA
22508
US

V. Phone/Fax

Practice location:
  • Phone: 540-972-8100
  • Fax: 540-972-8200
Mailing address:
  • Phone: 540-972-8100
  • Fax: 540-972-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: BASIONY T. HAGAR
Title or Position: OWNER
Credential: DDS
Phone: 540-972-8100