Basic Information
| Provider Information | |||||||||
| NPI: | 1669004255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENT | ||||||||
| FirstName: | BAILEE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 COBBLESTONE DR APT 208 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224016664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344300616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 HOPE RD STE 215 | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225547287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663114617 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 1306202940 | 01 | VA | TRICARE | OTHER |