Provider Demographics
NPI:1215031497
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:CHESTERFIELD COUNTY HEALTH DEPARTMENT DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MPH
Authorized Official - Phone:804-751-4385
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-0002
Mailing Address - Country:US
Mailing Address - Phone:804-751-1743
Mailing Address - Fax:804-751-4497
Practice Address - Street 1:9501 LUCY CORR CIR
Practice Address - Street 2:SUITE 404
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6697
Practice Address - Country:US
Practice Address - Phone:804-748-1752
Practice Address - Fax:804-751-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA107016OtherANTHEM BC BS OF VA
VA008450161Medicaid
0007461OtherDORAL DENTAL USA