Provider Demographics
NPI:1316603939
Name:LIFE BRIDGE DENTAL VA PLLC
Entity Type:Organization
Organization Name:LIFE BRIDGE DENTAL VA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR RCM
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:N
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-601-5250
Mailing Address - Street 1:DEPT CH 18077
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-8077
Mailing Address - Country:US
Mailing Address - Phone:212-686-3686
Mailing Address - Fax:615-468-0325
Practice Address - Street 1:4201 WILSON BLVD STE 190
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-4147
Practice Address - Country:US
Practice Address - Phone:212-686-3686
Practice Address - Fax:615-468-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty