Provider Demographics
NPI:1003352931
Name:COLONIAL HEIGHTS DENTAL CARE, INC.
Entity Type:Organization
Organization Name:COLONIAL HEIGHTS DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-520-1741
Mailing Address - Street 1:2018 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2310
Mailing Address - Country:US
Mailing Address - Phone:804-520-1741
Mailing Address - Fax:804-520-4750
Practice Address - Street 1:2018 BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2310
Practice Address - Country:US
Practice Address - Phone:804-520-1741
Practice Address - Fax:804-520-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014122571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty