MEDICARE: DENTAL ONE ASSOCIATES SOUTH RIDING PC

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	122300000X	Dentist		VA

General Provider Information

NPI Number	:	1265695712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL ONE ASSOCIATES SOUTH RIDING PC

Provider Business Mailing Address
First Line	:	25055 RIDING PLZ
Second Line	:	270
City	:	CHANTILLY
State	:	VA
Zip	:	20152-5917
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25055 RIDING PLZ
Second Line	:	270
City	:	CHANTILLY
State	:	VA
Zip	:	20152-5917
Country	:	US
Telephone Number	:	703-491-4489
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE DIRECTOR
Name	:	MIKE COLE
Credential	:
Telephone Number	:	727-726-1611

Provider Enumeration Date	:	07/04/2008
Last Update Date	:	10/29/2012

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