Provider Demographics
NPI:1124579396
Name:PEDIATRIC DENTISTRY & ORTHODONTICS OF VA, PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY & ORTHODONTICS OF VA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUBBE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-739-0963
Mailing Address - Street 1:13463 HULL STREET RD.
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2103
Mailing Address - Country:US
Mailing Address - Phone:804-739-0963
Mailing Address - Fax:804-739-0965
Practice Address - Street 1:13463 HULL STREET RD.
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2103
Practice Address - Country:US
Practice Address - Phone:804-739-0963
Practice Address - Fax:804-739-0965
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE, P.L.C.-PEDIATRIC DENTISTRY & ORTHODONTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-21
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty