Organization
LAKE RIDGE ENDODONTICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TODD E WYNKOOP DDS MS (OWNER/ENDODOTONTIST)
(703) 494-8624
Entity
Organization
Contact information
Practice address
12510 C LAKE RIDGE DR, WOODBRIDGE, VA 22192-2335
(703) 494-8624
(703) 497-1258
Mailing address
12510 LAKE RIDGE DR STE C, LAKE RIDGE, VA 22192-7501
(703) 494-8624
(703) 497-1258
Taxonomy
Speciality
Code
Description
License number
State
1223E0200X
Endodontics
Primary
041007464
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
174982
BLUE CROSS BLUE SHIELD
—
01
—
872859
UNITED CONCORDIA
—
Enumeration date
09/20/2006
Last updated
07/09/2008
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