Provider Demographics
NPI:1285664961
Name:BRICKHOUSE, TEGWYN (DDS)
Entity Type:Individual
Prefix:
First Name:TEGWYN
Middle Name:
Last Name:BRICKHOUSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5045
Mailing Address - Country:US
Mailing Address - Phone:804-828-9095
Mailing Address - Fax:804-827-1244
Practice Address - Street 1:521 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5045
Practice Address - Country:US
Practice Address - Phone:804-828-9095
Practice Address - Fax:804-827-1244
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04110000341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01-0025621Medicaid
VA0018308Medicaid
VA463655OtherANTHEM BC/BS