Provider Demographics
NPI:1447588991
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:VIRGINIA DEPARTMENT OF HEALTH DIVISION OF DENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR, OFFICE OF FAMILY HEALTH
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-864-7650
Mailing Address - Street 1:109 GOVERNOR ST RM 927
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-3623
Mailing Address - Country:US
Mailing Address - Phone:804-864-7774
Mailing Address - Fax:
Practice Address - Street 1:109 GOVERNOR ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-3623
Practice Address - Country:US
Practice Address - Phone:804-864-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental