Provider Demographics
NPI:1548747090
Name:JOOSSE FAMILY ORTHODONTICS LLC
Entity Type:Organization
Organization Name:JOOSSE FAMILY ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:JOOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-876-9593
Mailing Address - Street 1:4068 AMBASSADOR CIR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-1449
Mailing Address - Country:US
Mailing Address - Phone:757-876-9593
Mailing Address - Fax:
Practice Address - Street 1:1116 PROFESSIONAL DR STE A
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3378
Practice Address - Country:US
Practice Address - Phone:757-229-4181
Practice Address - Fax:757-221-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty