Provider Demographics
NPI:1508110057
Name:DOMINION HEALTH MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:DOMINION HEALTH MEDICAL ASSOCIATES
Other - Org Name:HALIFAX REGIONAL DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER DHG
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-517-3515
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0860
Mailing Address - Country:US
Mailing Address - Phone:434-517-8361
Mailing Address - Fax:434-517-8367
Practice Address - Street 1:101 AUBREYS LOOP
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5056
Practice Address - Country:US
Practice Address - Phone:434-517-8361
Practice Address - Fax:434-517-8367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty