Provider Demographics
NPI:1629089750
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:STAFFORD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAKOWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-899-4797
Mailing Address - Street 1:608 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5719
Mailing Address - Country:US
Mailing Address - Phone:540-899-4797
Mailing Address - Fax:540-899-4599
Practice Address - Street 1:1739 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7213
Practice Address - Country:US
Practice Address - Phone:540-288-2579
Practice Address - Fax:540-288-3796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA104852OtherDORAL
VA144853OtherANTHEM-MILLER