=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669888483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGDALE KIDZ DENTISTRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2014
-----------------------------------------------------
Last Update Date | 07/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5047 BACKLICK RD SUITE A
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-6045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-462-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5047 BACKLICK RD SUITE A
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-6045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-462-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TRICIA T TRAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-462-8855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401410663
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------