Provider Demographics
NPI:1558850776
Name:EAST COAST CENTRE FOR COSMETIC DENTISTRY AND FACIAL AESTHETICS
Entity Type:Organization
Organization Name:EAST COAST CENTRE FOR COSMETIC DENTISTRY AND FACIAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:CHICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-481-3305
Mailing Address - Street 1:3304 ARCTIC AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-2913
Mailing Address - Country:US
Mailing Address - Phone:757-481-3305
Mailing Address - Fax:757-481-7157
Practice Address - Street 1:3304 ARCTIC AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-2913
Practice Address - Country:US
Practice Address - Phone:757-481-3305
Practice Address - Fax:757-481-7157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010053661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770586216OtherPERSONAL NPI NUMBER