1801067285 NPI number — SOUTHSIDE ORAL & FACIAL SURGERY

Table of content: (NPI 1801067285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801067285 NPI number — SOUTHSIDE ORAL & FACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE ORAL & FACIAL SURGERY
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:
1801067285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11971 IRON BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23831-1458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-717-5275
Provider Business Mailing Address Fax Number:
804-748-4017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11971 IRON BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23831-1458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-717-5275
Provider Business Practice Location Address Fax Number:
804-748-4017
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TROTTER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
804-717-5275

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  4685 , 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: 9185610 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 219899 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 219900 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 386682 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 386686 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 259641 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9179952 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9202377 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005298 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005299 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 386684 . This is a "ANTHEM BC&BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9185611 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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