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General NPI Number Information
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NPI Number | 1225465131
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Entity Type | Organization
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Legal Business Name | TREASURED SMILES PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 10/09/2013
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Last Update Date | 10/09/2013
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Provider Practice Location Address
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Address Line | 1509 DODONA TER STE 105A
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City | LEESBURG
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State | VA
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Zip | 20175-4709
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Country | US
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Telephone | 571-293-0244
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Fax |
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Provider Business Mailing Address
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Address Line | 1509 DODONA TERRACE SUITE 105A
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City | LEESBURG
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State | VA
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Zip | 25405
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Country | US
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Telephone | 571-293-0244
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. CHRISTINE HICKERSON
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Credential |
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Telephone | 571-293-0244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401412920
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License Number State | VA
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