MEDICARE: DR. HOLLIE BLEVINS STACK DDS

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	1223G0001X	General Practice Dentistry	0401007703	VA

General Provider Information

NPI Number	:	1366458143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOLLIE BLEVINS STACK DDS

Provider Business Mailing Address
First Line	:	120 BEULAH RD NE
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4745
Country	:	US
Telephone Number	:	703-938-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 BEULAH RD NE
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4745
Country	:	US
Telephone Number	:	703-938-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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