Provider Demographics
NPI:1245800291
Name:RADIANCE DENTAL PLLC
Entity Type:Organization
Organization Name:RADIANCE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-739-6818
Mailing Address - Street 1:13841 HULL STREET RD # SITE5
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2056
Mailing Address - Country:US
Mailing Address - Phone:804-739-6818
Mailing Address - Fax:
Practice Address - Street 1:13841 HULL STREET RD # SITE5
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2056
Practice Address - Country:US
Practice Address - Phone:804-739-6818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental