MEDICARE: DALEWOOD MEDICAL ENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine

General Provider Information

NPI Number	:	1174549265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALEWOOD MEDICAL ENT

Provider Business Mailing Address
First Line	:	4158 DALE BLVD
Second Line	:
City	:	DALE CITY
State	:	VA
Zip	:	22193-2225
Country	:	US
Telephone Number	:	703-680-5959
Fax Number	:	703-730-1046

Provider Business Practice Location Address
First Line	:	4158 DALE BLVD
Second Line	:
City	:	DALE CITY
State	:	VA
Zip	:	22193-2225
Country	:	US
Telephone Number	:	703-680-5959
Fax Number	:	703-730-1046

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JENNIFER KULAK
Credential	:
Telephone Number	:	703-680-5959

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	12/27/2007

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