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General NPI Number Information
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NPI Number | 1528418951
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Entity Type | Organization
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Legal Business Name | AGAPE DENTAL STUDIO LLC
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Dates
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Enumeration Date | 06/16/2016
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Last Update Date | 06/16/2016
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Provider Practice Location Address
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Address Line | 5555 COLUMBIA PIKE SUITE #102
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City | ARLINGTON
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State | VA
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Zip | 22204-5852
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Country | US
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Telephone | 703-820-8282
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Fax |
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Provider Business Mailing Address
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Address Line | 5555 COLUMBIA PIKE SUITE #102
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City | ARLINGTON
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State | VA
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Zip | 22204-5852
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Country | US
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Telephone | 703-820-8282
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LIDIA TEKLE
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Credential | D.D.S
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Telephone | 703-820-8282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401412271
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License Number State | VA
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