Provider Demographics
NPI:1114216843
Name:SEABOARD DENTAL SERVICES
Entity Type:Organization
Organization Name:SEABOARD DENTAL SERVICES
Other - Org Name:RANDALL L. BITTNER DMD, FAMILY DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BITTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-425-1335
Mailing Address - Street 1:1112 LASKIN ROAD SUITE B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451
Mailing Address - Country:US
Mailing Address - Phone:757-425-1335
Mailing Address - Fax:
Practice Address - Street 1:1112 LASKIN ROAD SUITE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451
Practice Address - Country:US
Practice Address - Phone:757-425-1335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010080301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty