Provider Demographics
NPI:1558812719
Name:SOUTH RIVER DENTISTRY
Entity Type:Organization
Organization Name:SOUTH RIVER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:THAIR
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-378-7888
Mailing Address - Street 1:2301 ROBIOUS STATION CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2124
Mailing Address - Country:US
Mailing Address - Phone:804-378-7888
Mailing Address - Fax:
Practice Address - Street 1:2301 ROBIOUS STATION CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2124
Practice Address - Country:US
Practice Address - Phone:804-378-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty