Provider Demographics
NPI:1598838401
Name:LOUISA DENTAL CLINIC
Entity Type:Organization
Organization Name:LOUISA DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LILIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-972-6219
Mailing Address - Street 1:PO BOX 7546
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-7546
Mailing Address - Country:US
Mailing Address - Phone:434-972-6219
Mailing Address - Fax:434-972-4310
Practice Address - Street 1:101 WOOLFOLK AVE STE 202
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:VA
Practice Address - Zip Code:23093-4264
Practice Address - Country:US
Practice Address - Phone:540-967-4439
Practice Address - Fax:540-967-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008450421Medicaid