MEDICARE: M MINNIEVILLE DENTAL CARE PLLC

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

General Provider Information

NPI Number	:	1952907842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M MINNIEVILLE DENTAL CARE PLLC

Provider Business Mailing Address
First Line	:	4222 FORTUNA CENTER PLZ # 637
Second Line	:
City	:	DUMFRIES
State	:	VA
Zip	:	22025-1515
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14389 HEREFORD RD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2107
Country	:	US
Telephone Number	:	703-878-8000
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	GELLY RIVAS OSORIO
Credential	:
Telephone Number	:	703-589-7040

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	02/17/2021

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