Provider Demographics
NPI:1043717457
Name:CHESAPEAKE FAMILY AND IMPLANT DENTISTRY LLC
Entity Type:Organization
Organization Name:CHESAPEAKE FAMILY AND IMPLANT DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEBERLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-436-0026
Mailing Address - Street 1:CHESAPEAKE FAMILY AND IMPLANT DENTISTRY LLC
Mailing Address - Street 2:516 INNOVATION DR. SUITE 302
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-436-0026
Mailing Address - Fax:757-547-5658
Practice Address - Street 1:CHESAPEAKE FAMILY AND IMPLANT DENTISTRY
Practice Address - Street 2:516 INNOVATION DR. SUITE 302
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-436-0026
Practice Address - Fax:757-547-5658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010060631223G0001X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty