Provider Demographics
NPI:1346613528
Name:HAMPTON ROADS PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:HAMPTON ROADS PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Other - Org Name:HANBURY PEDIATRIC DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-369-1754
Mailing Address - Street 1:3120 KILN CREEK PKWY STE P
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5648
Mailing Address - Country:US
Mailing Address - Phone:757-369-1754
Mailing Address - Fax:757-234-8891
Practice Address - Street 1:237 HANBURY RD E STE 30
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-6622
Practice Address - Country:US
Practice Address - Phone:757-547-2134
Practice Address - Fax:757-410-4765
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAMPTON ROADS PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-10
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty