=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659724185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTISTRY OF KING GEORGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2016
-----------------------------------------------------
Last Update Date | 07/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10246 KINGS HWY
-----------------------------------------------------
City | KING GEORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22485-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-625-2007
-----------------------------------------------------
Fax | 540-371-9539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 THORNTON ST SUITE 101
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-371-3222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JUSTIN EDWARDS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 540-625-2007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401413260
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------