Provider Demographics
NPI:1053853911
Name:SU MCNEILL, DMD, PLLC
Entity Type:Organization
Organization Name:SU MCNEILL, DMD, PLLC
Other - Org Name:O'KEEFE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TELES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-710-6005
Mailing Address - Street 1:1232 W LITTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-1952
Mailing Address - Country:US
Mailing Address - Phone:757-440-7955
Mailing Address - Fax:757-489-5834
Practice Address - Street 1:1232 W LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-1952
Practice Address - Country:US
Practice Address - Phone:757-440-7955
Practice Address - Fax:757-489-5834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty