Provider Demographics
NPI:1568632370
Name:JEFFREY L EZEKIEL DDS PC
Entity Type:Organization
Organization Name:JEFFREY L EZEKIEL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EZEKIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-867-5003
Mailing Address - Street 1:3301 HAMPTON HWY STE M
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-2967
Mailing Address - Country:US
Mailing Address - Phone:757-867-5003
Mailing Address - Fax:757-867-5006
Practice Address - Street 1:3301 HAMPTON HWY STE M
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-2967
Practice Address - Country:US
Practice Address - Phone:757-867-5003
Practice Address - Fax:757-867-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7803532Medicaid