=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205253978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. PATRICIA REATEGUI D.D.S.P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 06/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 623 GARRISONVILLE RD 623 GARRISONVILLE ROAD
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-659-6650
-----------------------------------------------------
Fax | 540-657-0576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 279
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22555-0279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-659-6650
-----------------------------------------------------
Fax | 540-657-0576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. PATRICIA REATEGUI
-----------------------------------------------------
Credential | D.D.S.P.C.
-----------------------------------------------------
Telephone | 540-659-6650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401413627
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------