# PRINCE WILLIAM PARKWAY DENTAL PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Pine Dentistry
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154892677
- **Authorized official:** DALE MAYFIELD (PRESIDENT)
- **Authorized official phone:** (770) 916-5036

## Contact information

- **Practice address:** 2542 PRINCE WILLIAM PKWY STE 120, WOODBRIDGE, VA 22192-4149
- **Practice address phone:** (770) 916-9000
- **Mailing address:** 1090 NORTHCHASE PKWY SE STE 150, MARIETTA, GA 30067-6407
- **Mailing address phone:** (770) 916-5036
- **Mailing address fax:** (678) 285-4760

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223E0200X | Endodontics | — | NULL | — |
| 1223E0200X | Endodontics | — | — | — |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |
| 1223P0106X | Oral and Maxillofacial Pathology Dentistry | — | NULL | — |
| 1223P0106X | Oral and Maxillofacial Pathology Dentistry | — | — | — |
| 1223P0221X | Pediatric Dentistry | — | NULL | — |
| 1223P0221X | Pediatric Dentistry | — | — | — |
| 1223P0300X | Periodontics | — | NULL | — |
| 1223P0300X | Periodontics | — | — | — |

## Other

- **Enumeration date:** 12/10/2018
- **Last updated:** 12/10/2018