=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396217717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED DENTAL SLEEP MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2018
-----------------------------------------------------
Last Update Date | 12/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 LORTON STATION BLVD UNIT F104
-----------------------------------------------------
City | LORTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22079-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-625-4066
-----------------------------------------------------
Fax | 804-414-7491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5823 SPINNAKER COVE RD
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23112-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-625-4066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL PAGANO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 804-625-4066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------