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General NPI Number Information
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NPI Number | 1740667799
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Entity Type | Organization
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Legal Business Name | SEBASTIAN BOURONCLE DDS-1 PLLC
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Dates
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Enumeration Date | 04/29/2015
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 1900 OPITZ BLVD STE C
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3320
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Country | US
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Telephone | 703-494-0820
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Fax | 703-499-9430
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Provider Business Mailing Address
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Address Line | 1900 OPITZ BLVD STE C
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3320
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Country | US
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Telephone | 703-494-0820
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Fax | 703-499-9430
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. VIRGINIA T DE CASTRO
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Credential |
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Telephone | 703-494-0820
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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 | 15L05992
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License Number State | VA
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