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General NPI Number Information
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NPI Number | 1518465939
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Entity Type | Organization
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Legal Business Name | ALEXANDRIA OLD TOWN DENTAL PLLC
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Dates
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Enumeration Date | 01/31/2018
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 1421 PRINCE ST STE 140
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City | ALEXANDRIA
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State | VA
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Zip | 22314-2771
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Country | US
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Telephone | 703-549-1331
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Fax | 703-549-0480
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Provider Business Mailing Address
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Address Line | 1421 PRINCE ST STE 140
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City | ALEXANDRIA
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State | VA
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Zip | 22314-2771
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Country | US
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Telephone | 703-549-1331
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Fax | 703-549-0480
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. EDDIE SEYMOUR LONGMAN
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Credential | DDS
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Telephone | 703-549-1331
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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 | 0401004117
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License Number State | VA
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