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General NPI Number Information
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NPI Number | 1760386122
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Entity Type | Organization
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Legal Business Name | LAKE PLAZA DENTAL CARE PC
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Dates
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Enumeration Date | 10/07/2026
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Last Update Date | 10/07/2026
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Provider Practice Location Address
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Address Line | 36101 GOODWIN DRIVE
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City | LOCUST GROVE
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State | VA
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Zip | 22508
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Country | US
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Telephone | 540-972-8100
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Fax | 540-972-8200
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Provider Business Mailing Address
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Address Line | 36101 GOODWIN DRIVE
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City | LOCUST GROVE
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State | VA
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Zip | 22508
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Country | US
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Telephone | 540-972-8100
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Fax | 540-972-8200
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Authorized Official
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Title or Position | OWNER
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Name | BASIONY T. HAGAR
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Credential | DDS
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Telephone | 540-972-8100
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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 |
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License Number State | NULL
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