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General NPI Number Information
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NPI Number | 1356539100
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Entity Type | Organization
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Legal Business Name | LAKE MANASSA DENTAL CENTER
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Dates
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Enumeration Date | 10/05/2007
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Last Update Date | 10/05/2007
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Provider Practice Location Address
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Address Line | 7915 LAKE MANASSAS DR STE 115
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City | GAINESVILLE
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State | VA
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Zip | 20155
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Country | US
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Telephone | 646-641-8825
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Fax |
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Provider Business Mailing Address
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Address Line | 6911 STANWICK SQ
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City | GAINESVILLE
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State | VA
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Zip | 20155-4424
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Country | US
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Telephone | 646-641-8825
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | LONG NGUYEN
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Credential | D.D.S.
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Telephone | 646-641-8825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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