Provider Demographics
NPI:1336655315
Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Other - Org Name:NEW TOWN DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:4939 COURTHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2687
Mailing Address - Country:US
Mailing Address - Phone:757-259-0741
Mailing Address - Fax:
Practice Address - Street 1:4939 COURTHOUSE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2687
Practice Address - Country:US
Practice Address - Phone:757-259-0741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty