Provider Demographics
NPI:1295008985
Name:SOUTHSIDE FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:ADRENA
Authorized Official - Last Name:PARRIS-WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-520-5009
Mailing Address - Street 1:3505 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1319
Mailing Address - Country:US
Mailing Address - Phone:804-520-5009
Mailing Address - Fax:804-520-0901
Practice Address - Street 1:3505 BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1319
Practice Address - Country:US
Practice Address - Phone:804-520-5009
Practice Address - Fax:804-520-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-12
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty