Provider Demographics
NPI:1184215139
Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Other - Org Name:CEDAR LAKES DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1305 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-7105
Mailing Address - Country:US
Mailing Address - Phone:757-337-4090
Mailing Address - Fax:757-819-7844
Practice Address - Street 1:1305 CEDAR RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-7105
Practice Address - Country:US
Practice Address - Phone:757-337-4090
Practice Address - Fax:757-819-7844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-02
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty