1720873912 NPI number — SIMPLY SMILE FAMILY & COSMETIC DENTISTRY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720873912 NPI number — SIMPLY SMILE FAMILY & COSMETIC DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIMPLY SMILE FAMILY & COSMETIC DENTISTRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720873912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 RIVER DON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23188-8421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-815-1553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5215 MONTICELLO AVE STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23188-8232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-276-3029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2025

Additional Information

Authorized Official

Authorized Official Last Name:
HOGAN
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
ROBINSON
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
540-815-1553

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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