Provider Demographics
NPI:1053657171
Name:CHARLES S. LLEWELLYN III
Entity Type:Organization
Organization Name:CHARLES S. LLEWELLYN III
Other - Org Name:A DIVISION OF ALANTIC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SILAS
Authorized Official - Last Name:LLEWELLYN
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-428-2571
Mailing Address - Street 1:933 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3172
Mailing Address - Country:US
Mailing Address - Phone:757-428-2571
Mailing Address - Fax:757-422-4236
Practice Address - Street 1:933 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3172
Practice Address - Country:US
Practice Address - Phone:757-428-2571
Practice Address - Fax:757-422-4236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4010062461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty