Provider Demographics
NPI:1134671514
Name:COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-366-0330
Mailing Address - Street 1:931 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-4200
Mailing Address - Country:US
Mailing Address - Phone:757-366-0330
Mailing Address - Fax:757-366-0550
Practice Address - Street 1:931 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-4200
Practice Address - Country:US
Practice Address - Phone:757-366-0330
Practice Address - Fax:757-366-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411210305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649318247OtherNPI
VA1992010953OtherTHAMES NPI