Provider Demographics
NPI:1447433578
Name:TEAM DENTAL AT RIVER OAKS
Entity type:Organization
Organization Name:TEAM DENTAL AT RIVER OAKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ENON
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-221-9759
Mailing Address - Street 1:16689 RIVER RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4630
Mailing Address - Country:US
Mailing Address - Phone:703-221-9759
Mailing Address - Fax:703-221-2782
Practice Address - Street 1:16689 RIVER RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4630
Practice Address - Country:US
Practice Address - Phone:703-221-9759
Practice Address - Fax:703-221-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8593302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization