Provider Demographics
NPI:1326118167
Name:PEREZ, AGUSTIN SEBASTIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:SEBASTIAN
Last Name:PEREZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 DENBIGH BLVD
Mailing Address - Street 2:STE 5A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4427
Mailing Address - Country:US
Mailing Address - Phone:757-877-6003
Mailing Address - Fax:757-833-7063
Practice Address - Street 1:710 DENBIGH BLVD
Practice Address - Street 2:STE 5A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4427
Practice Address - Country:US
Practice Address - Phone:757-877-6003
Practice Address - Fax:757-833-7063
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010075841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA054957OtherBCBS
VA9182624Medicaid
VA587049OtherUNITED CONCORDIA