Provider Demographics
NPI:1578247094
Name:PENINSULA PERIODONTICS AND IMPLANTS PLLC
Entity Type:Organization
Organization Name:PENINSULA PERIODONTICS AND IMPLANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-258-7778
Mailing Address - Street 1:7151 RICHMOND RD STE 305
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7234
Mailing Address - Country:US
Mailing Address - Phone:757-258-7778
Mailing Address - Fax:
Practice Address - Street 1:1194 BIG BETHEL RD STE B
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1906
Practice Address - Country:US
Practice Address - Phone:757-850-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty