# LAKE RIDGE ENDODONTICS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1205933405
- **Authorized official:** DR. TODD E WYNKOOP DDS MS (OWNER/ENDODOTONTIST)
- **Authorized official phone:** (703) 494-8624

## Contact information

- **Practice address:** 12510 C LAKE RIDGE DR, WOODBRIDGE, VA 22192-2335
- **Practice address phone:** (703) 494-8624
- **Practice address fax:** (703) 497-1258
- **Mailing address:** 12510 LAKE RIDGE DR STE C, LAKE RIDGE, VA 22192-7501
- **Mailing address phone:** (703) 494-8624
- **Mailing address fax:** (703) 497-1258

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223E0200X | Endodontics | 041007464 | VA | Yes |

## Other

- **Enumeration date:** 09/20/2006
- **Last updated:** 07/09/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 174982 | BLUE CROSS BLUE SHIELD | — |
| 01 | — | 872859 | UNITED CONCORDIA | — |