Provider Demographics
NPI:1609038975
Name:MERCADO, ROMINA
Entity type:Individual
Prefix:DR
First Name:ROMINA
Middle Name:
Last Name:MERCADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5249 DUKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2907
Mailing Address - Country:US
Mailing Address - Phone:703-751-4344
Mailing Address - Fax:
Practice Address - Street 1:5249 DUKE ST STE 101
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2907
Practice Address - Country:US
Practice Address - Phone:703-751-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401412775122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program