Provider Demographics
NPI:1629098199
Name:DAVID B PEMBERTON DDS PC
Entity Type:Organization
Organization Name:DAVID B PEMBERTON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-233-6811
Mailing Address - Street 1:101 COWARDIN AVENUE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224
Mailing Address - Country:US
Mailing Address - Phone:804-233-6811
Mailing Address - Fax:804-230-0980
Practice Address - Street 1:101 COWARDIN AVENUE
Practice Address - Street 2:SUITE 303
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224
Practice Address - Country:US
Practice Address - Phone:804-233-6811
Practice Address - Fax:804-230-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA077681OtherANTHEM
00762638OtherUNITED CONCORDIA
VA172260OtherANTHEM
VA7815042Medicaid