Provider Demographics
NPI:1053604512
Name:CARLOS ALAN HERESI, DDS, PC
Entity type:Organization
Organization Name:CARLOS ALAN HERESI, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HERESI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-371-6929
Mailing Address - Street 1:2501 FALL HILL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3345
Mailing Address - Country:US
Mailing Address - Phone:540-371-6929
Mailing Address - Fax:
Practice Address - Street 1:2501 FALL HILL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3345
Practice Address - Country:US
Practice Address - Phone:540-371-6929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014125331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty