Provider Demographics
NPI:1003928938
Name:NORTHUMBERLAND COUNTY DENTAL CLINIC
Entity Type:Organization
Organization Name:NORTHUMBERLAND COUNTY DENTAL CLINIC
Other - Org Name:THREE RIVERS HEALTH DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DEPT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-758-2381
Mailing Address - Street 1:6373 NORTHUMBERLAND HWY - SUITE B
Mailing Address - Street 2:P O BOX 69
Mailing Address - City:HEATHSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22473
Mailing Address - Country:US
Mailing Address - Phone:804-758-2381
Mailing Address - Fax:804-758-4828
Practice Address - Street 1:6373 NORTHUMBERLAND HWY - SUITE B
Practice Address - Street 2:
Practice Address - City:HEATHSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22473
Practice Address - Country:US
Practice Address - Phone:804-758-2381
Practice Address - Fax:804-758-4828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004548251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA106879OtherDORAL (VA SMILES)
VA8451176Medicaid