1295964955 NPI number — PEDIATRIC DENTISTRY OF VIRGINIA, PLLC

Table of content: (NPI 1295964955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295964955 NPI number — PEDIATRIC DENTISTRY OF VIRGINIA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC DENTISTRY OF VIRGINIA, 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:
6
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:
1295964955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8203 CENTER PATH LANE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MECHANICSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-746-7382
Provider Business Mailing Address Fax Number:
804-746-3025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8203 CENTER PATH LANE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-746-7382
Provider Business Practice Location Address Fax Number:
804-746-3025
Provider Enumeration Date:
07/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ZIMA
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
804-746-7382

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  0401411085 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 0401412165 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9179294 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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