Provider Demographics
NPI:1467798603
Name:JACK MAVROMATIS, DDS, LTD.
Entity Type:Organization
Organization Name:JACK MAVROMATIS, DDS, LTD.
Other - Org Name:A DIVISION OF ATLANTIC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAVROMATIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-496-9123
Mailing Address - Street 1:2248 SUNSTATES CT STE 103
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1553
Mailing Address - Country:US
Mailing Address - Phone:757-496-9123
Mailing Address - Fax:757-496-2083
Practice Address - Street 1:2248 SUNSTATES CT STE 103
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1553
Practice Address - Country:US
Practice Address - Phone:757-496-9123
Practice Address - Fax:757-496-2083
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty