Provider Demographics
NPI:1073704219
Name:PEMBERTON, DAVID BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRENT
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COWARDIN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2078
Mailing Address - Country:US
Mailing Address - Phone:804-233-6811
Mailing Address - Fax:804-230-0980
Practice Address - Street 1:101 COWARDIN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-2078
Practice Address - Country:US
Practice Address - Phone:804-233-6811
Practice Address - Fax:804-230-0980
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000762638OtherUNITED CONCORDIA
VA077683OtherANTHEM
WI165313OtherDORAL DENTAL
VA7815042Medicaid
PA001701144OtherUNITED CONCORDIA
VA172260OtherANTHEM