Provider Demographics
NPI:1114127537
Name:DAVID R. TEBBENKAMP DDS PC
Entity Type:Organization
Organization Name:DAVID R. TEBBENKAMP DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:TEBBENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-388-3511
Mailing Address - Street 1:21788 AZEN RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:VA
Mailing Address - Zip Code:24236-4236
Mailing Address - Country:US
Mailing Address - Phone:276-388-3511
Mailing Address - Fax:276-388-3163
Practice Address - Street 1:21788 AZEN RD
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:VA
Practice Address - Zip Code:24236-4236
Practice Address - Country:US
Practice Address - Phone:276-388-3511
Practice Address - Fax:276-388-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA228633OtherANTHEM-BLUE CROSS BLUE SH