Provider Demographics
NPI:1407081268
Name:FRIENDLY FACES PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FRIENDLY FACES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JB
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:757-397-9801
Mailing Address - Street 1:446 EFFINGHAM ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3416
Mailing Address - Country:US
Mailing Address - Phone:757-397-9801
Mailing Address - Fax:757-397-9805
Practice Address - Street 1:446 EFFINGHAM ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3416
Practice Address - Country:US
Practice Address - Phone:757-397-9801
Practice Address - Fax:757-397-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008200025Medicaid