Provider Demographics
NPI:1538318175
Name:COMMONWEALTH OF VIRGINIA/STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA/STATE DEPARTMENT OF HEALTH
Other - Org Name:PENINSULA HEALTH CENTER-DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-594-7305
Mailing Address - Street 1:416 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1927
Mailing Address - Country:US
Mailing Address - Phone:757-594-7096
Mailing Address - Fax:757-594-7449
Practice Address - Street 1:416 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1927
Practice Address - Country:US
Practice Address - Phone:757-594-7096
Practice Address - Fax:757-594-7449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223D0001X251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975103Medicaid
VA4975103Medicaid